Health inspection·April 10, 2025

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #44's late entry social service progress note, written by Assistant Heath Care Administrator #658 and dated 04/03/25, revealed on 03/26/25 he spoke with Resident #44's sister in regard to completing a bed hold and the sister stated she would do anything they have to keep her room. Review of Resident #44's bed hold agreement document dated 03/26/25 revealed a telephone interview with the resident's sister revealed the sister agreed to the bed hold policy and expenses. Review of a social service note dated 04/03/25 revealed Resident #44 returned to the facility. Interview with Resident #44 on 04/07/25 at 10:04 A.M. revealed she was not notified she was past her 20 days of paid care and was paying out of pocket. The resident was hospitalized and stated she had to have a wound vacuum applied to her knee. Her sister called the facility and spoke to Assistant Health Care Administrator #658 and was never informed of the expenses incurred in a bed hold. Resident #44 stated she was never informed verbally nor in writing of the bed hold policy and had incurred a large amount of out-of-pocket money owed to the facility. The resident stated she was her own person, and her sister was not the one to make financial decisions for her. Interview with Resident #44's sister on 04/07/25 at 10:04 A.M. verified she was not informed of the bed hold policy. Interview with the Administrator on 04/07/25 at 1:25 P.M. verified the facility failed to inform Resident #44 in writing of the bed hold policy on 03/26/25. Review of the undated facility policy titled, Out of Residence Policy, revealed the facility will ascertain from the resident or responsible party either prior to or during the absence if the resident intends to return to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 2 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 observation, resident family member and staff interview, medical record review, review of staff meeting documents and education materials, facility policy review, and review of a facility job description for certified medication aides (CMAs), the facility failed to ensure staff were working within their scope of practice related to CMAs administering as needed medications. This affected one (#64) of two residents reviewed for pain. The facility census was 90. Residents Affected - Few Findings include: Review of the medical record for Resident #64 revealed she was admitted on [DATE] with diagnoses of congestive heart failure (CHF), diabetes mellitus type two, anxiety, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed she was cognitively impaired. At the time of medical record review for Resident #64 an MDS assessment was in progress for a significant change for admission to hospice services. Review of the care plan initiated April 2025 for Resident #64 revealed a care plan for pain with interventions to assess affects of unrelieved pain and notify the physician for pain medication adjustment, assess complaints of sudden/unusual/worsening pain and report to physician, assess the need to change as needed pain medication to a routine if resident was having difficulty anticipating pain medication needs, assist with position changes for comfort, and non-pharmacological methods of comfort. Review of the current physician orders dated April 2025 for Resident #64 revealed she was prescribed the pain medication Tylenol 650 milligrams (mg) every six hours pro re nata (PRN, meaning as needed) for pain or fever. The order was prescribed and in place since admission and admission to hospice services on 04/07/25. Review of Resident #64's nursing progress notes dated 04/04/2025 at 10:54 A.M. revealed the resident was crying out in pain and PRN Tylenol was administered and the overseeing nurse was notified. Review of the pain assessment documentation for Resident #64 revealed she had documented pain on 04/04/25 at 10:55 A.M. Further review of the pain assessment documentation for Resident #64 revealed following administration of Tylenol her pain was rated as a seven and the Tylenol was ineffective. Review of the nursing note dated 4/4/2025 at 10:55 A.M., generated by the electronic medication administration record (eMAR) for Resident #64 revealed Tylenol was administered for pain and the pain was rated at a six. Review of the nursing progress note dated 4/4/2025 at 2:28 P.M., generated by the eMAR for Resident #64, revealed the Tylenol was not effective and the follow-up pain was rated at a seven. Observation on 04/07/25 at 10:18 A.M. of Resident #64 revealed she was laying in bed on her back, moaning, and her breathing had a gurgling sound. Resident #64's daughter-in-law was at the bedside. Concurrent interview with Resident #64's daughter-in-law stated Resident #64 had been declining and the family was asked to consider hospice care. Resident #64's daughter-in-law stated the resident's family decided yesterday (04/06/25) and notified the facility on which hospice provider they chose, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 3 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 and were now waiting for hospice to come for their assessment and possible admission. Resident #64's daughter-in-law further stated she arrived at approximately 9:15 A.M. on 04/07/25 and the nurse communicated the nurse practitioner had been in to evaluate Resident #64 earlier that morning and ordered medication for comfort. Observation on 04/07/25 at 11:49 A.M. of Resident #64 revealed she was laying in bed, with the head of bed elevated, and had a wash cloth to her forehead. Resident #64 moved her head side-to-side and was breathing out of her mouth with non-labored shallow breaths with continued gurgling sound during breathing. Resident #64 had continuous oxygen running at two liters by way of nasal cannula and her family remained at the bedside. Interview on 04/08/25 at 2:52 P.M. with Licensed Practical Nurse (LPN) #612 stated if a certified medication aide (CMA) reported ineffective pain control the expectation would be for the overseeing nurse to conduct an assessment and attempt non-pharmacological methods of pain control such as repositioning. LPN #612 verified there was no documentation for a nursing assessment for pain control, no further treatment for pain, and no notification to the physician for uncontrolled pain for Resident #64. Further interview with LPN #612 stated the CMA that provided care on 04/04/25 for Resident #64 was CMA #584 and LPN #597 was assigned to oversee CMA #584 on 04/04/25. Interview on 04/08/25 at 3:35 P.M. with LPN #597 verified she worked on 04/04/25 and was not notified of uncontrolled pain for Resident #64 by CMA #584. Interview on 04/09/25 at 10:39 A.M. with the Director of Nursing (DON) stated on 04/04/25 the Tylenol administered to Resident #64 was by CMA #584 and it was out of her scope of practice to assess for pain. The DON further stated when a CMA was working and PRN medication was warranted, the CMA was required to notify the overseeing nurse for an assessment and direction for administration of the PRN medication. The DON further stated she interviewed the staff, and LPN #597 reported she was not notified of Resident #64's uncontrolled pain; and interview with CMA #584 reported she administered Resident #64 Tylenol before notifying the overseeing nurse. Further interview with the DON stated the CMA regulations were recently updated and included duties CMAs could now practice which included administration of insulin via an insulin pen only, administration of narcotics, and administration of PRN medications. The DON further stated the facility reviewed these updated regulations for CMAs, and the facility chose to allow for CMAs to administer insulin by way of insulin dial pen only with training and the facility policy continued to prohibit CMAs from administering narcotic medications and PRN medications without the assessment from the overseeing nurse first. Review of the staff meeting conducted on 03/17/25 for all nurses and CMAs to review the expectation of the nurse and the CMAs and update on the facility policy regarding the recent regulation changes for CMAs. Review of the sign-in sheet of this meeting revealed CMA #584 was present at the meeting and received the updated facility policy. Review of the presentation material revealed CMAs, per facility policy, were not permitted to administer PRN medications without a nurse assessment and narcotics continued to not be permitted for administration by a CMA. Interview on 04/10/25 at 7:54 A.M. with CMA #584 verified she was working on 04/04/25 and caring for Resident #64 when she was in calling out in pain and was different than her usual behavior of yelling. CMA #584 verified she administered the PRN Tylenol to Resident #64 on 04/04/25. Review of the undated facility job description for CMA revealed a certified medication aide will have their tasks delegated by their supervising LPN or registered nurse (RN). In addition to passing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 4 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 medication, CMAs will also monitor resident conditions, document, and report any condition changes, and monitor for drug reactions. CMAs are only allowed to observe and notify the nurse of any change in condition, and may not administer any PRN medication without notifying a nurse of the observation and need and the nurse completing the assessment and giving verbal consent to administer a PRN medication. Review of the facility policy titled, Pain Management, dated June 2024, revealed staff will observe for non-verbal and verbal indicators which may indicate the presence of pain and report to the overseeing nurse. The facility will use the pain assessment tool. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team such as nurse practitioners, physicians, nurses, or pharmacists. Review of the facility policy titled, Provision of Quality of Care, dated January 2023, revealed the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. All employees are responsible for following established policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 5 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 and staff interview, and facility policy review, the facility failed to ensure physician orders for pain were maintained to provide effective pain management. This affected one (#86) of two residents reviewed for pain. The facility census was 90. Residents Affected - Few Findings included: Review of Resident #86's medical record revealed an admission date of 01/31/25. Diagnoses included malnutrition and acute renal disease. Review of Resident #86's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident required scheduled pain medication and opioid use for pain control daily. Review of Resident #86's current care plan revealed she had the potential for pain related to chronic pain, osteoarthritis, and low back pain. Interventions included listening to the resident's concerns, advise the resident to request pain medication before pain becomes severe, and assess complaints of pain and report to the medical doctor. Review of Resident #86's nurses note dated 03/16/25 revealed she was readmitted to the facility after a laminectomy (a surgical procedure on the spinal cord). Review of Resident #86's physician order dated 03/16/25 revealed the resident was ordered the pain medication acetaminophen oral tablet 325 milligrams (mg) with instructions to give two tablets by mouth every four hours as needed for pain. Review of Resident #86's physician order dated 04/01/25 revealed the resident was ordered hydrocodone-acetaminophen (opioid pain medication) tablet 5-325 mg to be administered as needed for pain once daily related to diseases of the spinal cord. The end date for the order was indefinite. Review of Resident #86's skilled evaluation dated 04/07/25 at 12:05 A.M. revealed the resident complained of pain in her medial back (spine) with a level of seven on a 10-point pain scale. Relaxation techniques were encouraged and the resident's position was changed. Further review revealed non-medication interventions were not effective and as needed medication was provided. Review of Resident #86's medication administration record (MAR) for April 2025 revealed acetaminophen 325 mg was administered on 04/08/25 at 1:15 A.M. and at 8:43 A.M. for a pain rating of seven. Hydrocodone-acetaminophen was administered not administered on 04/08/25. Interview with Resident #86 on 04/08/25 at 7:20 A.M. revealed the resident had requested pain medication at 5:15 A.M. on 04/08/25 and received no medication. She rated her back pain as eight to nine out of 10. The resident stated staff informed her they could not obtain the medication from the locked medication dispensing system. Interview with Licensed Practical Nurse (LPN) #594 on 04/08/25 at 7:25 A.M. revealed Resident #86 did receive acetaminophen on 04/08/25, but there was not a current order for hydrocodone-acetaminophen. LPN #594 stated the physician was due to round anytime and they would ask for an updated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 6 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 0697 prescription at that time. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Pain Management, dated June 2024, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 7 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to address dementia care and treatment. This affected one (#23) of one residents reviewed for dementia related daily care and stimulation. The facility census was 90. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including Alzheimer's disease, dementia, coronary artery disease, hypertension, anxiety disorder, chronic pain, osteoporosis, anemia, major depression, type II diabetes mellitus, atrial fibrillation, and chronic kidney disease stage four. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was assessed with moderately impaired cognition, utilized a walker and wheelchair for mobility, required supervision or touching assistance with activities of daily living (ADLs), was continent of bowel and bladder, received a mechanically altered diet, was not at risk for development of pressure ulcers, and received insulin injections, antipsychotic medication, antidepressant medication, anticoagulation medication, and diuretic medication. Review of a nursing plan of care dated 08/11/24 was revised to address Resident #23's risk for fluctuating cognitive state/progressive cognitive deficit related to dementia and Alzheimer's disease. Interventions included to administer medication to help address the resident's cognitive deficit per physician order; monitor for side effects/adverse reaction and notify the physician if these are suspected or observed; encourage the resident to attempt simple tasks unassisted as able; encourage to speak about pleasant memories as needed; gently redirect the resident in the event that he/she makes an inappropriate choice; give cues/supervision for daily decision-making; give medications as ordered; intervene for unsafe decisions; monitor for changes in cognitive status and notify the physician if these are observed or suspected; notify family for material needs; physician consultation as needed; provide reorientation as needed during daily care activities; and provide simple explanations prior to initiating or assisting with care and reminders as needed. Further review revealed no resident individualized or specific interventions were documented. In addition on 08/12/24 a plan of care was initiated to address Resident #23's psychosocial well-being and activities which noted Resident #23 had a need for interpersonal interaction, established own goals, had a strong identification with past roles, lost roles, new to the facility, and withdrawal from activities of interest. The resident voiced she it was more difficult to do some activities she once enjoyed, such as reading and baking. Interests include reading when feeling up to it, watching television, and resting. She voiced having little pleasure or interest in doing things. Interventions included to allow the resident to vent/express thoughts, needs, and feelings; talk with the resident during care to provide socialization and reorient as needed; encourage the resident to attend activities and praise for doing so; and encourage the resident to maintain current level of independence in all simple choices. There were no resident specific points of interest were listed or alternative examples of sensory stimulation were provided. Observation on 04/08/25 at 9:29 A.M. noted Resident #23 in bed with the lights off, eyes closed, and the room quiet. There was no stimulation or activity was being provided. At 11:51 A.M., Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 8 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #23 was seated in a recliner at the bedside with no radio, television, books, or stimulation observed. On 04/09/25 at 10:26 A.M., Resident #23 was seated in a recliner with her feet to the floor. There was no meaningful stimuli or activity being provided and the room was silent with the lights off. At 12:07 P.M., the resident was in her room and reclined in a chair with her eyes closed. There was no meaningful stimuli or activity engagement provided. On 04/10/25 at 8:00 A.M., Resident #23 was observed in bed with her eyes closed and the room was quiet with the lights off. On 04/08/25 at 1:50 P.M., interview with Activity Assistant (AA) #622 stated Resident #23 spent much of her time in her room, sleeping. AA #662 stated the resident was provided with one-on-one visits once weekly and was not aware of any residents specific activity or stimulation engagement for Resident #23. On 04/10/25 at 8:10 A.M. interview with Activity Director (AD) #626, during a review of Resident #23's activity interest, verified no documentation was available indicating activities or related engagement that were provided. On 04/10/25 at 9:22 A.M., additional interview with AD #626 stated Resident #23 was spoken to following the previous interview and noted Resident #23 had interest in various types of music, movies, reading, and the walls in the resident's room also lacked pictures or visual stimuli. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 9 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of a menu, review of a meal ticket, and review of the facility policy, the facility failed to offer alternate food choices when the resident did not eat well from the offered meal. This affected one (#42) of three residents reviewed for dining observation. The facility census was 90. Findings include: Review of the medical record for Resident #42 revealed an admission date of 04/26/16 with diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 revealed the resident was severely cognitively impaired and required set-up for eating. Review of the current physician orders dated April 2025 for Resident #42 revealed she was ordered a fortified regular diet and for staff to check the refrigerator for homemade meals provided from family, and if food was available from family, please offer the homemade food during mealtime. Review of the care plan revised March 2025 for Resident #42 revealed she was at risk for poor oral intake with interventions in place for a fortified regular diet and needed assistance with eating. Review of the menu for 04/07/25 revealed the lunch served was Salisbury steak, roasted potato wedges, and peas and carrots. Review of the meal ticket for Resident #42 revealed no documented dislikes. Observation on 04/07/25 at 12:28 P.M., during dining observation, revealed Resident #42 was not offered substitute foods when she did not eat well for lunch. Continued observation during lunch for Resident #42 revealed she was assisted by Certified Nurse Aide (CNA) #530 and CNA #541, and neither of them offered a substitute when Resident #42 did not eat well. Review of the certified nurse aide (CNA) documentation for Resident #42 dated 04/07/25 revealed her meal intake for lunch on 04/07/25 was documented as zero percent (0%), which indicated Resident #42 ate between 0 and 25 of her meal. Interview on 04/07/25 at 1:06 P.M. with CNA #541 verified she did not offer an alternate meal or tried any other source of intake for Resident #42 for lunch. CNA #541 verified Resident #42 ate less than 25% of her meal for lunch. Review of the facility undated staff guidelines titled, Dining Room Expectations, revealed staff are to offer substitute meals for any unwanted items or food uneaten. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 10 of 11 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 366290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairlawn Haven 407 E Lutz Rd Archbold, OH 43502 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were stored in a manner to prevent spoilage and spoiled foods were discarded. This had the potential to affect all residents receiving food from the kitchen with the exception of one (#244) resident the facility identified that received nothing by mouth. The facility census was 90. Findings include: Observation on 04/07/25 from 7:50 AM to 8:10 A.M. revealed the walk-in cooler contained four containers of fresh strawberries with a whitish fuzzy growth on them, a bag of baby carrots that were open, unlabeled, and undated, and a tray of pastries and brownies that were uncovered, unlabeled, and undated. The tray of pastries and the tray of browns were thrown away and were hard when they were moved on the tray to throw in the garbage can. Interview on 04/07/25 at 7:56 A.M. with Assistant Dietary Manager (ADM) #700 verified strawberries contained mold, and confirmed the opened, unlabeled, and undated bag of baby carrots and the tray of pastries and brownies. ADM #700 further stated the pastries and brownies were from meals the previous day. Review of the facility policy titled, Food and Supply Storage, revised January 2025, revealed staff must cover, label, and date unused portions or open packages, and sort produce daily and remove spoiled pieces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366290 If continuation sheet Page 11 of 11