Health inspection·May 3, 2021

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, resident interview, staff interview, and review of facility policy, the facility failed to ensure one Resident (#15) of one reviewed was provided proper interventions to potentially prevent constipation. The facility's census was 43. Residents Affected - Few Findings include: Medical record review for Resident #15 revealed an admission of 11/17/20. Diagnoses included, multiple fractures of ribs, type II diabetes, atrial fibrillation (irregular heartbeat), and constipation. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #15's orders revealed orders for GlycoLax 17 grams, once per day, as needed (PRN) with a start date of 11/17/20, Colace 100 milligrams (mg) two times a day with a start date of 02/12/21, and Miralax 17 grams once per day with a start date of 03/25/21. Review of Resident #15's Bowel and Bladder by Shift Chart revealed from 02/06/21 to 02/11/21 (six days) Resident #15 had no bowel movement documented. Review of Resident #15's Medication Administration Record (MAR) for February 2021, revealed the PRN order for GlycoLax was not administered the whole month of February 2021. Review of Resident #15's Bowel and Bladder by Shift Chart revealed from 03/06/21 to 03/10/21 (five days) Resident #15 had no bowel movement documented. Review of Resident #15's MAR March 2021 revealed PRN order for GlycoLax was not administered the whole month of March 2021. Interview on 04/26/21 at 4:15 P.M. with Resident #15 revealed he was once constipated for a week and he told staff, however they did not provide him with any relief. Interview on 04/28/21 at 4:11 P.M. with the Director of Nursing (DON) verified all of Resident #15's bowel movements should be documented on the Bowel and Bladder by Shift Chart. The DON verified lack of bowel movements from 02/06/21 to 02/11/21 and from 03/06/21 to 03/10/21. The DON further verified Resident #15's PRN orders for GlycoLax was not initiated or administered the whole month of February 2021 and March 2021. Review of facility policy titled, Bowel Protocol Guidelines, revised 11/09/17 revealed the facility would use bowel stimulants for residents with constipation and an Ineffective Bowel Pattern Event should be initiated for any resident not having a bowel movement within 72 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366252 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 366252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Leipsic 901 East Main Street Leipsic, OH 45856 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure one resident was free from falls when personal care was provided by one staff member, instead of the required two. This affected one Resident (#10) of three reviewed for falls. The facility census was 43. Findings include: Medical record review for Resident #10 revealed an admission date of 11/13/20 with diagnoses including, type II diabetes, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #10 required extensive assistance of two staff for bed mobility and toileting. Interview on 04/26/21 at 11:18 A.M. with Resident #10 revealed she had a fall during incontinence care. Resident #10 revealed a State Tested Nursing Assistant (STNA) rolled her to the side to perform care and she fell out of bed. Resident #10 could not recall the date of when the incident happened. Interview on 04/28/21 at 4:44 P.M. with Resident #10 revealed STNA #500 was the aide providing incontinence care when she rolled out of the bed. Resident #10 revealed she will not allow staff to provide incontinence care unless there are two staff members present since the fall. Interview on 04/29/21 at 10:24 A.M. with STNA #500 verified there was an incident that happened in February 2021, however she could not recall the exact date. STNA revealed Resident #10 was wedged between her bed and the wall, however did not fall to the floor. The STNA revealed she was providing incontinence care to Resident #10 by herself and when rolled Resident #10 over, she got wedged between her bed and wall. She revealed four additional staff members came to assist to get the resident back in bed. Interview on 04/29/21 at 10:26 A.M. with the Assistant Director of Nursing (ADON) verified she was not aware Resident #10 had been wedged between her bed and wall while one STNA was providing personal care. Interview on 04/29/21 at 11:42 A.M. with Licensed Practical Nurse (LPN) #511 verified there was an incident where Resident #10 was wedged between her bed and wall. She revealed it happened either towards the end of February 2021 or beginning of March 2021. She further revealed she was not the residents nurse, however came to help assist the resident back in bed. Interview on 04/29/21 at 1:13 P.M. with LPN #533 verified there was an incident where Resident #10 became stuck in-between her bed and the wall. LPN #533 revealed she was Resident #10's nurse at time of the incident and Resident #10 voiced no concerns after the incident. Interview on 04/29/21 at 4:00 P.M. with STNA #555 verified Resident #10 required two staff person to assist with incontinence care and she had always required assistance of two staff members. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366252 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 366252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Leipsic 901 East Main Street Leipsic, OH 45856 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to accurately document an incident/fall in a resident's medical record. This affected one Resident (#10) of one reviewed for accurate documentation. The facility census was 43. Findings include: Medical record review for Resident #10 revealed an admission date of 11/13/20 with diagnoses including, type II diabetes, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #10 required extensive assistance of two staff for bed mobility and toileting. Review of Resident #10's progress notes for February 2021 and March 2021 revealed no evidence of any documentation of incidents or falls. Interview on 04/26/21 at 11:18 A.M. with Resident #10 revealed a State Tested Nursing Assistant (STNA) rolled her to the side to perform care and she fell out of bed. Resident #10 could not recall the date of when the incident happened. Interview on 04/28/21 at 4:44 P.M. with Resident #10 revealed STNA #500 was the aide providing incontinence care when she rolled out of the bed. Resident #10 revealed she will not allow staff to provide incontinence care unless there are two staff members present since the incident. Interview on 04/29/21 at 10:24 A.M. with STNA #500 verified there was an incident that happened in February 2021, however she could not recall the exact date. STNA revealed she was providing incontinence care to Resident #10 by herself and when rolled Resident #10 over, she got wedged between her bed and wall. She revealed four additional staff members came to assist to get the resident back in bed. Interview on 04/29/21 at 11:42 A.M. with Licensed Practical Nurse (LPN) #511 verified there was an incident where Resident #10 was wedged between her bed and wall. She revealed it happened either towards the end of February 2021 or beginning of March 2021. She further revealed she was not the resident's nurse, however came to help assist the resident back in bed. Interview on 04/29/21 at 1:13 P.M. with LPN #533 verified there was an incident where Resident #10 became stuck in-between her bed and the wall. LPN #533 revealed she was Resident #10's nurse at time of the incident. LPN #533 stated Resident #10 voiced no concerns after the incident took place. She could not recall if she documented the incident/fall in the resident's record. Interview on 04/29/21 at 10:26 A.M. the Assistant Director of Nursing (ADON) verified there was no documentation in Resident #10's medical record of the incident/fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366252 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 366252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Leipsic 901 East Main Street Leipsic, OH 45856 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 Based on medical record review, observation, staff interviews, and facility policy review, the facility failed to ensure appropriate signage was placed on the door of one Resident (#20) in quarantine status, and failed to ensure one Resident (#13) remained in quarantine status. This had the potential to affect all 43 residents of the facility. Residents Affected - Many Findings include: 1. Review of Resident #20's medical record revealed an admission date of 01/31/17. The resident had a hospital stay from 04/17/21 through 04/24/21. Observation on 04/26/21 at 11:59 A.M. revealed there was no sign on the resident's door to indicate transmission-based precautions. Interview on 04/26/21 at 12:05 P.M. with Registered Nurse (RN) #401 verified Resident #20 had been on transmission-based precautions due to having a hospital stay and the resident's door did not have signage. Review of facility policy titled COVID-19 Guidelines for Contact/Droplet Precautions, dated 07/29/20, revealed when a resident is on contact/droplet precautions a sign is posted on the resident's door alerting of precautions. 2. Review of Resident #13's medical record revealed an admission date of 02/19/20. Physician orders revealed the resident was to be on droplet precautions from 04/21/21 to 04/27/21. Observation on 04/26/21 at 12:08 P.M. revealed Resident #13 was sitting in the lounge area with other residents. Interview at the time of the observation with RN #403 verified Resident #13 had been on isolation precautions for influenza and should be in her room. Review of facility policy titled, Guidelines for Droplet Precautions, dated 03/19/20, revealed a resident under droplet precautions should be placed in a private room if possible. Limit the movement of the resident from the room to essential purposes only. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366252 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 366252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Leipsic 901 East Main Street Leipsic, OH 45856 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation., staff interview, and review of facility policy, the facility failed to ensure proper maintenance was completed on a wheelchair being used by one Resident (#16) of one observed. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #16's medical record revealed an admission date of 11/20/20 with diagnoses including unspecified cerebrovascular disease (stroke), heart failure, and history of falling. Observation on 04/27/21 at 11:51 A.M. revealed Resident #16 was sitting in her wheelchair. There were two screws exposed on the right arm rest of the wheelchair protruding through the foam padding. The exposed screws were approximately one inch long. Interview on 04/27/21 at 11:55 A.M. with Registered Nurse (RN) #405 verified Resident #16's wheelchair had exposed protruding screws on the right arm rest of the wheelchair. Review of facility policy titled, Guidelines for General Use of Equipment, dated 08/01/16 revealed, the facility provides and maintains routine equipment for the general use for the resident population. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366252 If continuation sheet Page 6 of 6