Inspection·January 25, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure comprehensive care plans were developed for communication and significant weight loss. This affected three (#2, #9 and #14) out of eight residents reviewed for care plans. The facility census was 18. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 11/27/19. Diagnoses included chronic obstructive pulmonary disease, psychosis, hallucinations, dementia, cognitive communication deficit, difficulty walking, unsteadiness on feet, and chronic kidney disease. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 10/20/21, revealed the resident has severe cognitive impairment. The assessment also listed the resident as having moderate difficulty hearing and utilized a hearing aid. Review of Resident #14's current care plan did not address Resident #14's hearing loss and interventions to communicate with the resident. Additionally, observation on 01/18/22 at 10:32 A.M. of Resident #14 revealed the resident to be extremely hard of hearing. The resident did not have hearing aids in place and a white board had to be utilized to communicate with the resident. Interview on 01/18/22 at 5:04 P.M. with Licensed Practical Nurse (LPN) # 437 stated Resident #14 used to wear hearing aids and she believes the resident's family took them home. LPN #437 stated the staff communicate with the resident using a white board. The resident also has an portable hearing amplifier but she chooses not to use it. Interview on 01/19/22 at 11:17 A.M. with State Tested Nursing Assistant (STNA) #427 stated she didn't know of the resident ever having hearing aids. STNA #427 stated the resident has a portable hearing amplifier and the resident does not like to use it. Interview on 01/20/22 at 1:08 P.M. with the Director of Nursing (DON) verified Resident #14's care plan did not address the resident's hearing loss. 2. Review of medical record for Resident #9 revealed an admission date of 08/14/13. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, depressive disorder, gastroesophageal reflux disease, anxiety disorder, essential tremor, brief psychotic disorder, and paranoid personality disorder. Review of Resident #9's MDS assessment, dated 12/15/21, revealed the resident to have severe cognitive impairment. The assessment listed the resident as having weight loss and no therapeutic diet. Review of Resident #9's monthly physician orders dated January 2022 revealed an order for a regular diet. Review of Resident #9's weights revealed a weight of 158 pounds on 06/02/21 and a weight of 138 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 0656 pounds on 12/02/21. This represented a 20 pound, or 12 %, weight loss in 180 days. Level of Harm - Minimal harm or potential for actual harm Review of the dietary note dated 12/08/21 revealed the resident had a weight warning. While the resident had a body mass index of 22.4, there had been a 12.1% weight loss over the prior 180 days. Resident #9 is on regular diet and intakes are 50-100% at meals. The resident refuses supplements. There were no further recommendations at this time. Continue to monitor monthly and make additional recommendations as needed. Residents Affected - Few Review of Resident #9's current care plan did not address the resident's significant weight loss. Interview on 01/20/22 1:54 P.M., Dietician #441 stated Resident #9 has had some weight loss and refuses supplements. Interview on 01/20/22 at 3:29 P.M., the Director of Nursing (DON) verified the resident's care plan had not been updated. 3. Review of Resident #2's medical record revealed an admission date of 03/03/21. Diagnoses included cerebrovascular disease, vascular dementia, moderate protein calorie malnutrition, repeated falls, generalized anxiety, atrial fibrillation, and heart disease. Review of Resident #2's MDS assessment, dated 01/05/22, revealed Resident #2 was not able to complete the cognition assessment. Resident #2 required extensive assistance with eating. Resident #2 was noted to cough or choke during meals or when swallowing medications. Resident #2 had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months and she was not on a prescribed weight loss program. Resident #2 was receiving a mechanically altered diet. Review of Resident #2's care plan, revised 01/07/22, revealed supports and interventions for risk for altered nutrition and hydration. Resident #2's care plan did not include supports and interventions for her significant weight loss. Review of Resident #2's Nutrition assessment dated [DATE] revealed Resident #2 had a significant weight loss of 5% in 30 days and 10% in 180 days. Recommendations included speech therapy to assess diet for increased intakes. Interview on 01/20/22 at 1:08 P.M., the DON verified Resident #2's care plan did not address the resident's significant weight loss. Review of the facility policy titled Baseline Care Plan Policy, revised January 2019, revealed the care plan would reflect the resident's stated goals and objective and include interventions that address his/her current needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident care plans were revised. This affected three (#7, #9, #14) out of eight residents reviewed for care plan revisions. The facility census was 18. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 11/27/19. Diagnoses included chronic obstructive pulmonary disease, psychosis, hallucinations, dementia, cognitive communication deficit, and chronic kidney disease. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 10/20/21, revealed the resident had severe cognitive impairment. The assessment listed the resident as being at risk for pressure ulcers and having no pressure ulcers. Review of nurse's note for Resident #14 dated 12/28/21 revealed during morning care the resident was noted to have a racquetball size bruise to posterior aspect of the left knee. Review of Resident #14's weekly skin sweep dated 01/10/22 revealed the previously documented racquetball size lump now a blackened fluid filled area. Previous ABD was saturated with dark red/tan drainage. Review of Resident #14's physician orders revealed on 01/10/22 to obtain a culture and sensitivity of the hematoma on back of left leg and apply warm compress to site to promote absorption every morning and as needed On 01/15/22 an order was received to administer the antibiotic azithromycin 250 milligrams (mgs) orally at bedtime for four days, apply ABD pad to back of left leg over hematoma site, wrap area loosely with ACE wrap, and as the area shrinks, apply ace wrap tighter. Review of weekly skin sweeps revealed on 01/17/22 the posterior left calf was reddened due to fluid filled draining cyst. Review of Resident #14's current care plan revealed the resident's care plan was not updated regarding the resident's current posterior upper left left wound. Interview on 01/20/22 at 1:08 P.M. with the Director of Nursing (DON) verified Resident #14's care plan did not address the resident's posterior upper left left wound. 2. Review of medical record for Resident #9 revealed an admission date of 08/14/13. Diagnoses included Alzheimer's disease, gastroesophageal reflux disease (GERD), depressive disorder, anxiety disorder, and paranoid personality disorder. Review of Resident #9's MDS assessment dated [DATE] revealed the resident to severe cognitive impairment. Review of the plan of care, last revised 11/04/16, indicated Resident #9 was at risk for altered nutrition related to diagnosis of GERD and frequent pain medications with potential for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 0657 Level of Harm - Minimal harm or potential for actual harm gastrointestinal discomfort. An intervention dated 09/03/20 revealed the resident will take omeprazole (medication for GERD) as ordered. Review of physician orders revealed the omeprazole was discontinued on 11/30/21. The plan of care was not updated. Residents Affected - Few Interview on 01/20/22 at 3:29 P.M. with Director of Nursing (DON) stated the resident had a choking episode in December 2021 and was evaluated at the hospital and returned the same day. Review of Speech Therapy (ST) evaluation dated 12/10/21 revealed Resident #9 was seen during lunch and was consuming food safely. There were no signs or symptoms of aspiration. No therapy recommended at this time. Review of nurse's note for Resident #9 dated 01/13/22 revealed the resident began choking at dinner, followed by a small emesis. The resident refused supper and returned to her room. Review of physician orders revealed on 01/13/22 an order for lansoprazole (a medication for treating GERD) was received. Review of the plan of care revealed it was not revised following Resident #9's choking and emesis episodes and the medication used to treat the resident's GERD was not updated. Interview on 01/20/22 at 3:29 P.M., the DON verified the resident's care plan had not been updated. 3. Review of Resident #7's medical record revealed an admission date of 07/24/13. Diagnoses included subluxation of right shoulder joint, muscle weakness, atrial fibrillation, panic disorder, anxiety disorder, major depressive disorder, and convulsions. Review of Resident #7's care plan, revised 01/18/22, revealed supports and interventions for self-care deficit and risk for falls. Resident #7's self-care deficit interventions included using a [NAME] lift for all transfers. Resident #7's fall risk description stated she used a [NAME] lift for transfers. The interventions noted Resident #7 used to use a [NAME] lift for transfers but she was getting distracted and would let go of the lift and try and move her feet off the platform. A ceiling lift was to be used for transfers. The fall risk description for the use of the [NAME] lift and the self-care deficit care plan were not updated to indicate Resident #7 now used a ceiling lift. Observation on 01/18/22 9:54 A.M. of Resident #7's room found a ceiling lift available for use and the sling for the ceiling lift positioned under Resident #7. Interview on 01/19/22 at 01/19/22 8:55 A.M. with State Tested Nursing Assistant (STNA) #421 revealed Resident #7 had a fall from her [NAME] lift because she let go during transfer. STNA #421 reported Resident #7 has since used the ceiling lift for safety purposes. Interview on 01/19/22 at 10:57 A.M. with Resident #7 verified she no longer used the [NAME] lift and now used the ceiling lift. Resident #7 reported she fell back in December 2021 and dislocated her shoulder falling after letting go and moving her feet on the [NAME] walker. Resident #7 reported the staff now use the ceiling lift because it was safer for her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 01/20/22 at 1:08 P.M. with the Director of Nursing (DON) verified Resident #7's care plan was not updated accurately for the type of lift Resident #7 used. Review of the facility policy titled Baseline Care Plan Policy, revised January 2019, revealed the care plan would reflect the resident's stated goals and objective and include interventions that address his/her current needs. Changes would be made as necessary, resulting from significant changes in condition or needs. Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to obtain and evaluate appropriate treatment, and removed an old dressing in a manner to prevent pain and tissue damage for one (#14) resident. This resulted in actual harm when Resident #14's ordered dressing was adhering to her open wound and was removed by the nurse without any interventions to loosen the dressing before removal. Resident #14 was noted to squeeze her eyes shut, grimace, tense her upper body, grab hold of the armrest with her hand, and pull her leg away when the dressing was removed. The wound was noted to be opened and actively bleeding following the immediate removal of the adhering dressing. Additionally, the facility failed to conduct a comprehensive wound assessment which including measurements of the wound for one (#14) resident out of one resident reviewed for wounds. The facility census was 18. Residents Affected - Few Findings Include: Review of Resident #14's medical record revealed an admission date of 11/27/19. Diagnoses included chronic obstructive pulmonary disease, psychosis, hallucinations, dementia, cognitive communication deficit, difficulty walking, and chronic kidney disease. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment listed the resident as being at risk for pressure ulcers and having no pressure ulcers. Review of Resident #14's nurse's note dated 12/28/21 revealed the resident was noted to have a raised racquetball sized bruise to the posterior aspect of the left knee. There were no measurements of the area. There were no additional assessments of the area until 01/08/22. Review of Resident #14's nurse's note dated 01/08/22 revealed ABD pad and kerlix were applied to left calf area due to black swollen fluid filled area. There were no measurements of the area. Review of Resident #14's nurse's note dated 01/09/22 revealed ABD pad and kerlix were applied to blackened fluid filled cyst behind left knee. Bloody discharge was noted on previous bandage. There were no measurements of the area. Review of Resident #14's weekly skin sweep dated 01/10/22 listed previously documented racquetball size lump now with blackened fluid filled area and previous ABD pad saturated with dark red/tan discharge. Review of Resident #14's physician orders dated 01/10/22 revealed the following obtain a culture and sensitivity of hematoma on back of left leg. Apply warm compress to site to promote absorption every morning and as needed. Review of Resident #14's wound culture final report dated 01/14/22 revealed moderate growth of staphylococcus aureus isolated. Review of physician orders dated 01/15/22 revealed an order for the antibiotic azithromycin 250 milligrams orally at bedtime for four days for area to posterior left knee, Apply ABD pad to back of left leg over hematoma site. Wrap area loosely with ACE wrap, as the area shrinks, apply ace wrap (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 tighter. Level of Harm - Actual harm Review of Resident #14's current care plan revealed the care plan did not address the resident's wound or wound infection. Residents Affected - Few Skin sweep dated 01/17/22 revealed posterior left calf had reddened area due to fluid filled cyst draining and brownish red discharge on previous dressing. There were no measurements of the area. Review of Resident #14's nurse's note dated 01/20/22 at 2:24 P.M. revealed post hematoma left posterior calf which measured 5 centimeters (cm) by 7 cm by <0.1 cm and was draining bright red blood. The note documented the resident noted to grimace during the dressing change. An ABD pad and ace wrap applied per order. Adaptic placed on wound under the ABD pad to prevent sticking to the wound. The physician was notified. Observation on 01/20/22 at 10:05 A.M. revealed Registered Nurse (RN) #439 completed a wound treatment for Resident #14's left posterior leg. The order was to apply an ABD pad over hematoma site and wrap with an ACE wrap. When RN #439 removed the old ABD pad from the wound upper left posterior leg, the pad was sticking to the wound and was not easily removable. RN #439 pulled the ABD pad off the area without any interventions to loosen the dressing. There was a moderate amount of bright red blood on the ABD pad and blood dripping from the wound immediately after removal of the ABD pad. The wound was was observed to be very large in size and open. As the nurse was removing the old ABD pad from the resident's wound the resident squeezed her eyes shut, grimaced, tensed her upper body, grabbed hold of the armrest with her hand, and pulled her leg away. Per surveyor intervention the RN measured the resident's wound and obtained a measurements documented in the 01/20/22 nurse's note. Interview on 01/20/22 10:05 A.M. with RN #439 stated Resident #14 had a large hematoma behind her left knee and then the wound opened up. RN #439 was unaware of when the area became an open wound. RN #439 verified the ABD dressing was sticking to Resident #14's wound on the left leg and it appeared to hurt the resident when she removed it. RN #439 stated she would contact the physician for a different treatment. Interview on 01/20/22 10:55 A.M., the Director of Nursing (DON) stated Resident #14 had a hematoma behind her left knee which started on 01/08/22 and was a fluid filled area. DON stated the hematoma opened up on 01/19/22 and verified there was no documentation of the area becoming an open wound. The DON verified there were no measurements taken of the area until 01/20/22. Review of facility policy titled Treatment Guidelines for Pressure Injury and Wounds, dated 06/05/18, revealed a very important consideration in establishing and implementing a treatment program for any type of wound is an individualized treatment program for each Elder. For infected wounds, cover with Mepilex border foam and change everyday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were provided ongoing range of motion (ROM). This affected one (#13) of two residents reviewed for limited range of motion. The facility census was 18. Finding Include: Review of Resident #13's medical record revealed an admission date of 09/26/18. Diagnoses included hemiplegia and hemiparesis, atrial fibrillation, hypertension, hypersomnia, muscle weakness, cerebral infarction, kidney failure, heart failure, abnormal posture, type II diabetes, and anemia. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 10/13/21, revealed Resident #13 was cognitively intact. Resident #13 was totally dependent on staff for bed mobility, transfer, and toilet use. Resident #13 required extensive assistance with dressing and personal hygiene. Resident #13 was noted to have an upper extremity impairment on one side and and a lower extremity impairment on both sides. Resident #13 received passive range of motion three times during the seven calendar days of the review period. Review of Resident #13's care plan revised 01/18/22 revealed supports and interventions for self-care deficit, risk for pain, recently discharged from physical therapy and would participate in range of motion supine or seated leg stretches. Review of the record revealed Resident #13 was discontinued from physical therapy and occupational therapy on 10/19/21. Resident #13 was referred by therapy at discharge to nursing to perform passive ROM to the upper body, left shoulder ROM, and lower extremity ROM during care. Review of Resident #13's State Tested Nursing Assistant (STNA) tasks for the last 30 days revealed ROM was only completed on 01/15/22, 01/16/22, and 01/19/22. It was noted Resident #13 refused on ROM on 12/23/21, 12/24/21, 01/01/22, 01/02/22, and 01/05/22. ROM was identified as not completed on 19 days and documented as not applicable. Interview on 01/18/22 at 10:17 A.M. with Resident #13 revealed she had limited movement with her arm and her legs. Resident #13 reported she was not receiving ROM exercises from the staff like she was supposed to. Resident #13 reported she was done with physical therapy but she was still supposed to be getting ROM. Resident #13 stated she could only do what she could do without their help. Resident #13 stated her husband tried to help her when he visited but the facility was not providing supports. Interview on 01/20/22 at 9:16 A.M. with the Director of Nursing (DON) verified Resident #13 was documented as receiving ROM only three times in the last 30 days. The DON reported Resident #13's husband did ROM with Resident #13 at times but they did not have a way of tracking those ROM interactions. Review of the undated facility policy titled, Range of Motion (ROM), revealed ROM program required planning and consistency. Whenever possible ROM should be preformed on a daily basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 - Some 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 the Dish Machine Temperature Log, the facility failed to ensure dishes were properly sanitized in the dishwashers in the 101 House. This affected all nine residents (#2, #6, #7, #10, #12, #13, #268, #269, and #270) who resided in the 101 House. The facility census was 18. Findings Include: Observation on 01/18/22 at 1:26 P.M. of State Tested Nursing Assistant (STNA) #415 found her running the dishwasher following the lunch meal in the 101 House. The dishwasher was noted to be a low temperature, chemical sanitization machine using chlorine for sanitation. The observed wash temperature was 120 degrees Fahrenheit (F) and rinse temperature of 129 degrees F. STNA #415 completed a test strip for chlorine sanitation levels and found the level were 25 parts per million (ppm). STNA #415 verified the proper level for sanitation was at least 50 ppm and dishwasher was not at the proper level of chlorine for sanitation. Observation on 01/18/22 at 1:38 P.M. of a second cycle of the dishwasher found the chemical sanitation level continued to be 25 ppm. STNA #415 verified it was still not reaching the proper sanitation level. She checked the chemicals and found them to be full and connected properly. STNA #415 stated she would notify the maintenance staff to have the machine serviced. Review of the Dish Machine Temperature Log for lunch on 01/18/22 revealed the chemical sanitation level was documented as 50 ppm. Interview on 01/18/22 at 2:12 P.M. with STNA #415 verified the chemical sanitization level for the lunch meal on 01/18/22 was 25 ppm and the documented 50 ppm was inaccurate. Review of the log titled Dish Machine Temperature Log, dated January 2022, revealed the dish wash machine temperatures should be between 120 degrees F and 140 degrees F and the chlorine sanitizer should be 50 ppm. Resident #2, #268, #269, #10, #6, #7, #12, #13, and #270 resided in the 101 House. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 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 366402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge of Mennonite Home Communities of Ohio 101 Willow Ridge Drive Bluffton, OH 45817 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 observation and staff interview, the facility failed to prevent possible transmission of COVID-19 infection by failing to ensure the thermometer used for screening was properly disinfected between use by different persons. This had the potential to affect all 18 residents in the facility. The facility census was 18. Residents Affected - Many Findings include: Observations on 01/18/22 through 01/22/22 revealed surveyors had to self screen upon entrance into the facility on a sheet of paper. The surveyors used a hand held thermometer to obtain their temperatures upon entrance. The facility staff did not disinfect thermometer between uses nor was there disinfectant available to disinfect the thermometer between uses. Interview on 01/19/22 at 2:40 P.M. with State Tested Nurse Aide (STNA) #430 verified she did not disinfect the thermometer after use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366402 If continuation sheet Page 11 of 11