Inspection·October 31, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident Assessments were completed timely. This affected one (Resident #53) of one reviewed for timely Resident Assessments. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/31/23 with diagnoses of mild cognitive impairment and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had impaired cognition. Further review revealed no additional quarterly or comprehensive assessments were completed after 06/05/23. Interview on 10/24/23 at 12:37 P.M. with MDS Coordinator #228 confirmed Resident #53 was due for a quarterly assessment on 09/05/23. MDS Coordinator #228 further stated she normally received reminders from the Regional Office when assessments were due and could not determine why the quarterly assessment for Resident #53 was not completed. Review of the guidance provided by the facility revealed the October 2019 version of the Resident Assessment Instrument (RAI) manual indicated a quarterly assessment should be completed within 92 days from the previous assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 2 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an accurate Resident Assessment was completed for two (Residents #16 and #25) of two residents reviewed for accurate Resident Assessments. The facility census was 80. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 02/22/17 with diagnoses of urinary tract infection and neuromuscular dysfunction of the bladder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had an indwelling urinary catheter. Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 did not have an indwelling urinary catheter. Interview on 10/23/23 at 10:42 A.M. with Resident #16 revealed she had a urinary catheter. Observation at that time revealed catheter tubing and a covered catheter bag. Interview on 10/25/23 at 5:18 P.M. with MDS Coordinator #228 confirmed Resident #16 had a urinary catheter at the time of the MDS assessment completed 10/06/23 and the assessment was marked incorrectly. 2. Review of the medical record for Resident #25 revealed an admission date of 03/20/23 with diagnoses of depression and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had intact cognition and received a hypnotic medication four times during the previous seven days. Review of the physician orders from 09/01/23 through 09/11/23 revealed no medications classified as a hypnotic were prescribed for Resident #25. Review of the current physician orders for Resident #25 revealed an order dated 09/15/23 for trazodone (anti-depressant) 100 milligrams (mg), two tablets once daily. Review of a progress note dated 09/15/23 revealed Resident #25's trazodone dose was increased. Interview on 10/26/23 at approximately 4:00 P.M. with MDS Coordinator #228 confirmed she mis-coded trazodone as a hypnotic rather than an antidepressant and further confirmed Resident #25 did not receive a hypnotic during the lookback period for the assessment completed 09/11/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 3 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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, observation, and staff interview, the facility failed to ensure residents received sufficient assistance with Activities of Daily Living (ADL). This affected one (Resident #13) of three residents reviewed for ADL care. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included Alzheimer's disease, cerebrovascular disease, type two diabetes mellitus, hyperlipidemia, hypothyroidism, essential hypertension, dyspnea, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive one person assistance with personal hygiene. Review of the most recent care plan revealed Resident #13 required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included to allow the resident sufficient time to complete all or part of a task, do not rush the resident, encourage the resident to do as much as safely as possible for self, and observe for deterioration in ADL abilities, and report if changes in abilities occur. Observation on 10/24/23 at 8:03 A.M. of Resident #13 revealed the resident had a thick white build-up on upper and lower teeth around the gum line. The bottom teeth had a thicker layer than the top. Interview on 10/24/23 at 2:46 P.M. with State Tested Nursing Assistant (STNA) #170 verified providing care for Resident #13 throughout the shift. STNA #170 stated Resident #13 provides most of her own care and brushes her own teeth but needs a reminder. Subsequent observation of Resident #13's teeth revealed a thick white build-up on upper and lower teeth around the gum line with no change from the morning. STNA #170 verified Resident #13's teeth needed brushed. Observation on 10/25/23 at 10:54 A.M. revealed Resident #13 continued to have areas of the mouth between the teeth and gum line with white build-up. The areas appeared to improve from the day prior. Observation on 10/26/23 at 7:55 A.M. of Resident #13's teeth revealed the upper and lower teeth near the gum line had a white build-up. Subsequent interview with Registered Nurse (RN) #212 verified the teeth could be brushed a little better stating it has been worse in the past. Interview on 10/26/23 at 8:01 A.M. with STNA #173 verified Resident #13 requires staff to stand by her to ensure personal hygiene needs are met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 4 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of facility policy, the facility failed to include residents in activities that met their interests. This affected one (Resident #4) of one reviewed for activities. The facility census was 80. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an admission date of 12/12/14 with diagnoses of Down's syndrome and functional quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was rarely/never understood. Review of the comprehensive MDS assessment dated [DATE] for activity preferences revealed Resident #4 enjoyed listening to music and participating in religious activities or practices. Review of the Annual Life Enrichment assessment dated [DATE] revealed Resident #4 was rarely/never understood and family was not available for interview. Further review revealed Resident #4 enjoyed live entertainment, music, and it was somewhat important to him to participate in religious practices, specifically Catholic blessings. Review of the Life Enrichment Progress note dated 08/22/23 revealed Resident #4 required small groups and decreased environmental stimuli, and one-on-one settings for successful activity participation and engagement. Further review revealed Resident #4 liked music and music-related programs. Review of a One-on-One Needs Assessment, most recently completed 08/22/23, revealed Resident #4 should receive two one-on-one visits weekly, each lasting at least 15 minutes each. Review of care plan dated 07/11/17 revealed Resident #4's activities of interest includes music programs. Further review of the care plan revealed an intervention for Resident #4 to be provided with one-on-one activity visits one to two times per week. Review of the Activity Calendar dated 10/22/23 through 10/28/23 revealed the facility offered an average of eight activities daily. Observation on 10/23/23 at 10:37 A.M. revealed Resident #4's door closed with a single-pitch droning noise coming from his room. Upon entry to the room, Resident #4 appeared clean and groomed and was sitting in his wheelchair facing the television. Resident #4 continued to make the droning noise. Interview on 10/23/23 at 10:37 A.M. with Registered Nurse (RN) #224 confirmed Resident #4 had a developmental delay and his door was often closed because of his singing. Observation on 10/24/23 at 3:20 P.M. revealed activity staff playing the piano and residents gathered in the main dining room to sing along. The activity was scheduled from 3:00 P.M. until 4:00 P.M. Observation on 10/24/23 at 3:24 P.M. revealed Resident #4 in his room, lying in bed, awake and watching television. Resident #4's arms were folded behind his head. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 5 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0679 Level of Harm - Minimal harm or potential for actual harm Interview on 10/24/23 at 3:28 P.M. with State Tested Nurse Aide (STNA) #110 stated she was familiar with Resident #4 and was assigned to his hall. STNA #110 stated Resident #4 did not normally attend afternoon activities. Further, Resident #4 made his loud singing noise when he was in his wheelchair, whether in his room or in the common area. STNA #110 was not very familiar with the types of activities Resident #4 enjoyed except watching cartoons. Residents Affected - Few Interview on 10/24/23 at 3:37 P.M. with Activities Aide (AA) #132 knew Resident #4 attended the activity scheduled at 8:30 A.M. AA #132 stated Resident #4 used to attend the evening movies and some nights he would stay quiet and some nights he would be disruptive with his singing. AA #132 stated the reason Resident #4 was not in the current singing activity was because he typically was in bed after lunch and so he would not have been invited. Interview on 10/24/23 at 3:49 P.M. with Activities Director (AD) #102 confirmed Resident #4 liked to sing. AD #102 confirmed quarterly activity assessments were completed and the facility recently changed to a new computer system to track participation in activities. Interview on 10/24/23 at 4:24 P.M. with AA #108 revealed he did not invite Resident #4 to the singing activity and probably should have. At that time AA #193 joined the interview and stated Resident #4 was disruptive at times during group meetings due to the loud noise he made. Observation on 10/25/23 at 2:07 P.M. revealed Resident #4 in his room with the door closed. The sound of his single-tone noise could be heard through the closed door. Observation on 10/26/23 at 12:49 P.M. revealed STNA #133 taking Resident #4 to his room for a nap after lunch. Observation on 10/26/23 at approximately 2:15 P.M. revealed Catholic Mass service was conducted with music. Further observation revealed Resident #4 was not present. Observation on 10/26/23 at 3:15 P.M. revealed activity staff playing the piano and residents gathered in the dining room singing. Resident #4 was not present. Observation on 10/26/23 at 3:17 P.M. revealed Resident #4 lying in bed in his room blinking at the television and making noise. Interview on 10/26/23 at 3:18 P.M. with STNA #181 revealed she was familiar with Resident #4 and assigned to his hall. STNA #181 stated she knew Resident #4 liked music but was not at the music activity because he sleeping between lunch and dinner. STNA #181 stated Resident #4 went to the evening movie sometimes. Observation on 10/31/23 at 3:07 P.M. revealed Resident #4 at the choir activity in the dining room sitting next to AA #132. Resident #4 was not making any noise. Interview on 10/31/23 at 3:10 P.M. with AD #102 felt the facility made an effort to include Resident #4 in the activities he liked. AD #102 stated on Fridays Resident #4 is brought out to the nurses' station at approximately 3:30 P.M. to enjoy the Happy Hour scheduled from 3:00 P.M. until 4:00 P.M. AD #102 stated Resident #4 generally made his droning noise when he was in large groups, and therefore he was kept separated from the crowd at the nurses' station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 6 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Continued interview revealed the facility began using new activity software and the facility was unable to provide evidence of one-on-one visits with Resident #4. The facility provided evidence Resident #4 was included in an average of 2.25 activities per week from 09/24/23 through 10/24/23. Review of the policy, Individual Program Planning, dated 06/02/16, revealed individual programming ensures that all residents who are unable or unwilling to participate in group programs have consistent, goal oriented, and individualized recreation opportunities. Event ID: Facility ID: 366423 If continuation sheet Page 7 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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. **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 residents were timely assessed for therapy services. This affected one (Resident #41) of one reviewed for mobility. The facility census was 80. Findings include: Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included central cord syndrome at C4 level of cervical spinal cord, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, hyperlipidemia, essential hypertension, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive one person assistance with dressing and personal hygiene and extensive two-person assistance with bed mobility, transfers, and toilet use. Review of range of motion documentation dated 07/23/23 to 10/23/23 revealed Resident #41 received range of motion services 30 times in the last approximately 90 days. Further record review revealed no physician orders and the care plan did not identify range of motion (ROM) services. Review of progress notes dated 10/12/23 revealed Resident #41 and spouse made requests for ROM/therapy referral for ROM needs. Further review of the medical record revealed no therapy evaluation being completed. Interview on 10/23/23 at 4:12 P.M. with Resident #41 revealed the resident believed he should be receiving range of motion services twice a day but only receives range of motion services on second shift. Interview on 10/25/23 at approximately 3:00 P.M. with MDS Coordinator/Licensed Practical Nurse (LPN) 228 verified Resident #41 had made a request for therapy services on 10/12/23 during a care conference and no therapy evaluation had occurred. The delay in the referral was unknown. Interview on 10/26/23 at 3:20 P.M. with Physical Therapist #445 verified she was not aware of range of motion request on 10/11/23 until 10/25/23 and will evaluate the resident on 10/30/23. Interview on 10/31/23 at 8:19 A.M. with Physical Therapist #445 verified completing the therapy evaluation on 10/30/23. Physical Therapist #445 stated there was no decline in abilities but ROM does relieve discomfort and recommended aides provided ROM twice a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 8 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interview, staff interview, and review of facility policy, the facility failed to provide appropriate catheter care per standards of care to potentially prevent infection. This affected two (Residents #14 and #44) out of three reviewed for indwelling catheters. The current census is 80. Findings include: 1. Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 included diabetes, sleep apnea, lymphedema, presence of unigenital implants, urinary tract infections, and neuromuscular dysfunction of bladder. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, was incontinent of bowel and bladder, and required extensive two-person assist with transfers. Further review of the MDS assessment revealed the resident had an indwelling catheter. Review of Resident #44's care plan dated 08/2023 revealed a focus for bowel and bladder includes a catheter for the diagnosis of neurogenic bladder. Interventions included lab work per order, strap in place to prevent pulling out catheter, observe for complication such as infection, urethral trauma, stricture of bladder, or hydro nephrosis. Notify physician of changes, observe tubing avoid obstructions, record urinary output, provide assistance with catheter care and replace catheter per orders. Interview on 10/25/23 at 3:25 P.M. with Resident #44 revealed the resident stated she was frequently being treated for urinary tract infections due to the catheter. Resident #44 stated she felt the aides were not completing the care properly. Observation on 10/25/23 at 7:45 A.M. with STNA #165 performing catheter care on Resident #44 revealed the aide performed hand hygiene, applied gloves, prepared 2 washcloths, (one with water and soap and one with water), and 1 dry towel. STNA #165 was observed using one washcloth, identified by the aide as the washcloth with soap, and wiping the entire genital area crossing over from the outer part of the perineal area to the inner part of the perineal area multiple times. STNA #165 was observed washing the back perineal area to the front perineal area multiple times. STNA #165 verified during the observation, Resident #44 has had urinary tract infections frequently. STNA #165 was observed taking the washcloth, identified by the aide as the cloth with just water, and wiping the perineal area from the outer part to the inner part of the perineal area multiple times. STNA #165 was observed taking the dry towel and wiping Resident #44's perineal area from the outside to the inner area with the dry towel. STNA #165 was observed instructing Resident #44 to turn over to her left side so the aide could wash the back perineal area. STNA #165 was observed placing the drainage bag onto the bed near the resident's feet above the bladder level. STNA #165 was observed taking the washcloth, identified as the cloth with soap and water, and washing the back perineal area. STNA #165 was observed washing the back of the perineal area and then washing the inner front area. STNA was observed taking the washcloth, identified as the cloth with just water, and wiping from back perineal area to the front perineal area multiple times. STNA #165 was observed taking the dry towel and wiping the perineal area from back to front multiple times. During the observation the STNA #165 verified the aide uses only soap and water and 3 washcloths to complete all of the catheter care. The STNA verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 9 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the placement of the drainage bag was above the level of the bladder at the end of the observation and the aide was observed lowering the drainage bag back to the side of the bed. 2. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 include heart disease, obstructive uropathy, and Parkinson's disease. Review of Resident #14's MDS assessment dated [DATE] revealed the resident had intact cognition, was a one person assist with ADLs, and had an indwelling catheter. Review of Resident #14's care plan dated 07/2021 revealed a focus for bowel and bladder, resident used a Foley catheter. Interventions include provide catheter care, lab work per order, and observe for signs and symptoms of infection. Interview on 10/24/23 at 8:55 A.M. with Resident #14 revealed the resident stated he had recently been treated for a urinary tract infection. Resident #14 stated his indwelling catheter had recently been changed and he was receiving catheter care by the aides regularly. Observation on 10/26/23 at 9:40 A.M. with State Tested Nurse Aide (STNA) #165 and Administrator performing catheter care for Resident #14 revealed the resident was seated on a shower chair in the bathroom. STNA #165 was observed handing the resident his drainage bag, above the bladder, and then preparing the supplies for the care. The Administrator verified the drainage bag was above the bladder while the resident was holding the bag and the Administrator placed the bag below the bladder level onto the floor of the bathroom. STNA #165 was observed washing her hand, applying gloves, and wetting two washcloths, the aide applied soap to one washcloth, and placed the second wash cloth into the sink full of water. STNA #165 was observed using the soap washcloth, cleaning the indwelling catheter tubing from the ending of the tube and wiping towards the head of the resident's urethra. The Administrator instructed STNA #165 to wash away from the urethra and down the tubing in the opposite direction. STNA #165 was observed using the soap washcloth to wash around the outside of Resident #14's genital area towards the inside near the urethra. STNA #165 was observed using the same soap washcloth for the entire genital area before placing the soap washcloth back into the sink full of water with the other washcloth. STNA #165 was observed taking the other washcloth out of the sink and then wiping the entire genital area with the water washcloth. The Administrator instructed the aide to use a new washcloth due to her placing the soap washcloth back into the sink with the water washcloth. STNA #165 stated she did not bring any more washcloths into the bathroom. The Administrator retrieved new washcloths and instructed STNA #165 to repeat the catheter care. Interview on 10/26/23 at 9:52 AM with the Administrator verified the observation of STNA #165's catheter care and stated the care was not per the standard practice for care to prevent infections. Per the Administrator, STNA #165 had received education on the proper procedures for catheter care prior to the observation. Review of the facility's policy titled, Urinary Catheter Care, dated 12/31/22 revealed the staff are to maintain the drainage bag below the level of the bladder at all times to prevent backflow into the bladder. Staff are to ensure the bag and tubing remain off the floor. For females, use one area of the washcloth to wipe in a downward stroke, changing the area of the washcloth for each stroke. For males use the washcloth to cleanse around the glans around the meatus and then outward. Use a clean washcloth to rinse the catheter from the inner most part towards the skin to the outward part. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 10 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, and staff interview, the facility failed to ensure the provider responded in a timely manner to all pharmacy recommendations for gradual dose reductions of medications. This affected two (Residents #25 and #44) of five reviewed for unnecessary medications. The current census is 80. Findings include: 1. Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 include diabetes, sleep apnea, lymphedema, presence of urogenital implants, urinary tract infections, and neuromuscular dysfunction of bladder. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, was incontinent of bowel and bladder, and required extensive two-person assist with transfers. Further review of the MDS assessment revealed the resident had an indwelling catheter. Review of Resident #44's care plan dated 08/2023 revealed a focus for psychotropic drug use with interventions to administer medication per order, attempt a Gradual Dose Reduction (GDR) every two quarters for the first year of antidepressant and than yearly, notify physician for changes, and observe and record signs of sedation. Review of Resident #44's pharmacy recommendations revealed on 07/27/23 the pharmacist recommended reducing Zoloft (Selective Serotonin Reuptake Inhibitor - SSRI) from 50 milligrams (mg) daily to 25 mg daily. Per the recommendation the Certified Nurse Practioner (CNP) #450 did not respond to the recommendation until 10/25/23. Per the CNP notation on the recommendation, the reduction was not agreed upon due to 'recent infection' and increase in depression symptoms. Per the CNP #450 a reduction would cause adverse effect. Review of Resident #44's pharmacy recommendations revealed on 01/25/23 the pharmacist recommended reducing Zoloft from 50 milligrams (mg) daily to 25 mg daily. A notation on the recommendation was noted to not decrease Zoloft due to being 'decremental' the note was not signed or dated. No date for the notification of the provider was on the recommendation. Interview on 10/25/23 at 3:00 P.M. with Regional Registered Nurse (RN) #444 verified the pharmacist's recommendation were not replied to by the CNP in a timely manner for the 07/27/23 recommendation. Regional RN #444 verified there were no date on the reply for the 01/25/23 recommendation. Interview on 10/26/23 at 11:20 AM with CNP #450 verified she had not documented on the 07/27/23 recommendation until 10/25/23 when is was brought to her attention. Per CNP #450, the pharmacy recommendations are to be reviewed and documented on by the provider in a timely manner. CNP #450 verified she did not date the 01/25/23 recommendation. Per CNP #450 she has given verbal orders replying to the recommendations and stated it was procedure to document the date of the reply to the GDRs. 2. Review of the medical record for Resident #25 revealed an admission date of 03/20/23 with diagnoses heart disease and a heart attack. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 11 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0756 Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had intact cognition. Level of Harm - Minimal harm or potential for actual harm Review of a Pharmacy Recommendation form dated 07/03/23 revealed the pharmacist recommended a clarification for Resident #25's order for nitroglycerine. The pharmacist requested the order be updated to include directions for notifying the physician. Residents Affected - Few Review of a physician order dated 08/28/23 revealed Resident #25 should receive nitroglycerine as needed for chest pain and the physician should be notified after the third dose. Interview on 10/26/23 at 2:53 P.M. with Regional Registered Nurse (RRN) #444 confirmed the pharmacist's recommendation for clarification was dated 07/03/23 and the order was not modified until 08/28/23 and confirmed the facility did not respond timely to the pharmacist's recommendation. Review of the facility policy titled, Psychotropic Medications and Gradual Dose Reductions, with a review date of 12/31/22, revealed the pharmacist will review the residents' medications monthly and provide to the providers their recommendations for reductions. No timeframe for physician responses were detailed in the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 12 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of facility policy, the facility failed ensure residents were free from unnecessary psychotic medication by failing to to ensure as needed psychotropic medications were limited to 14 days and by failing to ensure psychotropic medication were not administered in an excessive dose for Resident #40. In addition, the facility failed to ensure psychotropic medication were prescribed with appropriate diagnosis, appropriate dosage and with administration instructions including defined administration parameters for Resident #58. This affected two (#40 and #58) of five residents reviewed for unnecessary medication. The facility census was 80. Findings include: 1. Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included Alzheimer's disease with late onset, type two diabetes mellitus, dementia with behavioral disturbance, hyperlipidemia, hypothyroidism, major depressive disorder recurrent severe with psychotic symptoms, anxiety disorder, bipolar disorder, and unspecified dementia with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was severely cognitively impaired. Review of the current care plan revealed Resident #40 was at risk for adverse consequences due to receiving antipsychotic medication for dementia with behaviors, restlessness, and agitation. Review of physician orders dated 10/11/23 to 04/11/24, revealed an order for ABH (Ativan two milligram (mg), Benadryl 12.5 mg, Haldol one mg per milliliter) syringe ointment with instructions to apply one syringe to skin/inner wrist every four hours as needed for anxiety. Review of physician orders dated 09/08/23 to 10/11/23, revealed an order for ABH (Ativan two mg, Benadryl 12.5 mg, Haldol one mg per milliliter) syringe ointment with instructions to apply one syringe to skin/inner wrist every four hours as needed (PRN) for anxiety. Review of the Medication Administration Record (MAR) revealed on 09/19/23, Resident #40 was administered ABH ointment at 1:27 P.M. and at 3:14 P.M. Interview on 10/26/23 at 3:01 P.M. with Regional Registered Nurse (RRN) #444 verified Resident #40's ABH ointment (psychotropic drug) PRN order from 09/08/23 to 10/11/23 and 10/11/23 to 04/11/24 was for more than 14 days with no rationale. Interview on 10/31/23 at approximately 3:30 P.M. with RRN #444 verified on 09/19/23, Resident #40 was administered two doses of ABH ointment in less than two hours with the physician for order every four hours as needed. 2. Review of the medical record revealed Resident #58 was admitted on [DATE]. Diagnoses included Alzheimer's disease with late onset, hypertensive heart disease with heart failure, osteoarthritis, hyperlipidemia, hallucinations, and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 13 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0758 Review of the MDS assessment, dated 09/29/23, revealed Resident #58 was severely cognitively impaired. Level of Harm - Minimal harm or potential for actual harm Review of the current care plan revealed Resident #58 was at risk for adverse consequences due to receiving antipsychotic medication for mood disturbance with dementia and at times exhibits violent behaviors with hallucinations. Residents Affected - Few Review of physician orders, dated 07/26/23 to 09/18/23, revealed an order for Ativan 0.5 g mg tablet as needed every two hours. Review of physician orders, dated 08/28/23 to 10/26/23, revealed an order for ABH (Ativan two mg, Benadryl 12.5 mg, Haldol one mg per milliliter) syringe ointment every four hours as needed for anxiety. The order did not include instructions for dosage or site to administer. The order does not include parameters in conjunction with other psychotropic/antianxiety as needed orders. Review of physician orders, dated 09/18/23 to 09/18/23, revealed an order for haloperidol decanoate solution 50 milligram/milliliter (mg/ml), administer two mg intramuscular one time. Review of physician orders, dated 09/18/23 to 09/27/23, revealed an order for lorazepam (Ativan), one mg, every two hours as needed. The order does not include parameters in conjunction with other psychotropic/antianxiety as needed orders. Review of physician orders, dated 09/27/23 to 10/23/23, revealed an order for lorazepam (Ativan), 0.5 mg, every two hours as needed. The order does not included parameters in conjunction with other psychotropic/antianxiety as needed orders. Review of physician orders, dated 10/23/23 to 03/23/23, revealed an order for lorazepam (Ativan), 0.5 mg, every two hours as needed. The order does not included parameters in conjunction with other psychotropic/antianxiety as needed orders. Review of physician orders, dated 10/14/23 to 10/14/23, revealed an order for haloperidol decanoate solution 100 mg/ml, administer one mg intramuscular one time. Review of the MAR, dated September 2023, revealed on 09/01/23 ABH cream as needed was provided at 1:11 A.M. and Ativan 0.5 mg as needed was provided at 3:28 P.M.; on 09/02/23 Ativan was provided at 5:41 P.M. (ABH cream not provided); on 09/07/23 ABH cream was provided 9:05 A.M. and Ativan 0.5 mg was provided at 5:46 P.M.; on 09/15/23 ABH cream was provided at 6:15 P.M. and Ativan 0.5 mg was provided at 8:38 P.M.; on 09/18/23 ABH cream was provided at 1:20 P.M. and Ativan was provided at 3:46 P.M.; on 09/22/23 Ativan was provided at 9:01 A.M. with ABH cream not provided prior; on 09/24/23 Ativan was provided at 9:43 A.M. and 3:46 P.M. with ABH cream not provided prior; and on 09/27/23 at 4:44 P.M. Ativan 0.5 mg was provided at the same time as the ABH cream. Review of the MAR, dated October 2023, revealed on 10/01/23 and 10/03/23 Ativan was administered with ABH cream not administered. On 10/12/23, ABH cream was administered at 7:13 P.M. and Ativan was administered at 7:29 P.M. Interview on 10/26/23 at 7:57 A.M. with Registered Nurse (RN) #212 verified the electronic record for the ABH ointment did not include instructions for dosage or site to administer. Subsequent observation verified the ABH ointment in the medication cart did display required dosage instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 14 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/26/23 at 11:22 A.M. with Certified Nurse Practitioner (CNP) #450 verified when a resident is prescribed ABH cream and Ativan/lorazepam as needed the ABH cream should be given first as needed due being the least invasive. Interview on 10/26/23 at 3:01 P.M. with RRN #444 verified when a resident is prescribed ABH cream and Ativan/lorazepam as needed the ABH cream should be given first as it is considered the least restrictive. RRN #444 verified the physician instructions do not provide parameters for the psychotropic medications. Interview on 10/31/23 at 4:35 P.M. with RRN #444 verified Resident #58 had been prescribed Haldol with no appropriate diagnosis. Review of the policy, Psychotropic Medication Usage and Gradual Dose Reductions, reviewed 12/31/22, verified residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with the appropriate diagnosis or documentation to support its usage. Orders for PRN (as needed) medications will have designated purpose for use. PRN order for psychotropic drugs are limited to 14 days, except as provided if the attending physician or prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 15 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, and staff interview, the facility failed to ensure meat was palatable. This affected four residents (#6, #30, #38 and #68) and had the potential to affect all residents on a regular diet. The facility identified 23 residents were not on a regular diet (#4, #7, #11, #12, #14, #15, #16, #19, #22, #24, #26, #31, #34, #40, #48, #53, #61, #64, #71, #72, #128, #228, and #229). The facility census was 80. Residents Affected - Some Findings include: Observations on 10/23/23 beginning at 12:03 P.M. in the main dining room during the noon meal revealed the main meal provided was chopped steak with mushroom gravy, red skin mashed potatoes, and vegetable medley. Observation on 10/23/23 at 12:05 P.M. in the restorative dining room revealed Resident #6 was eating her lunch unassisted. State Tested Nurse Aide (STNA) #165 was observed telling Resident #6 to slow down and chew or you're going to choke. The meat is very tough today. Observation on 10/23/23 at approximately 12:10 P.M. in the main dining room revealed Resident #38 received her meal. Resident #38 was observed to have difficulty cutting the meat. Continued observation revealed Resident #38 asked staff for a replacement meal because the meat was too tough to cut. Observation on 10/23/23 at approximately 12:15 P.M. in the main dining room revealed unidentified staff assisting Resident #68 by cutting his meat. Staff was heard to state, this is hard to cut. Interviews on 10/23/23 at approximately 12:20 P.M. with Resident #30 and Resident #68 reported the meat was undercooked and too tough to eat. Review of a test tray on 10/23/23 at 12:34 P.M. with Environmental Services Director (ESD) #125 confirmed the chopped steak was tough to cut. The surveyor and ESD #125 were able to chew the meat without notable difficulty. Observation on 10/23/23 at approximately 12:40 P.M. revealed Resident #30 eating hardboiled eggs. Interview on 10/24/23 at 1:15 P.M. with STNA #165 revealed there have been complaints from residents regarding the toughness of the meat. STNA #165 verified she told Resident #6 to slow down and not put too much in her mouth during lunch on 10/23/23 because the meat was too tough. Interview on 10/24/23 at approximately 1:20 P.M. with Dietary Manager (DM) #177 reported no complaints of meat from lunch the previous day. DM #177 was surprised she did not receive complaints because the chopped steak was hard to get tender when cooked for only three hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 16 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 food was stored appropriately. This had the potential to affect all residents residing in the facility. The facility identified all residents received food from the kitchen. Additionally, the facility failed to ensure staff used appropriate hand hygiene when handling ready-to-eat foods. This affected three (Residents #9 #128, #6) of three residents observed for meal preparation. The facility census was 80. Findings include: 1. Observations on 10/23/23 beginning at 8:27 A.M. in the freezer revealed a box of chicken nuggets open to air, a plastic tub labeled taco meat with the lid off, and a torn open bag of breaded fish filets. Interview with [NAME] #178 during the observation confirmed the items were open. Continued observation of the walk-in refrigerator revealed a bag of chopped lettuce open to air, a box of bacon lined with a plastic bag. The plastic bag was completely open and exposing all bacon in the box to the air, and containers of raspberries, blackberries and strawberries with a grey/green fuzzy substance on them. Interview with [NAME] #178 during the observation confirmed the items were open. Continued observation in the dry storage room revealed a box of sweet potatoes containing approximately 12 potatoes with sprouts approximately two inches long growing out of each potato. Interview on 10/23/23 at 8:40 A.M. with [NAME] #178 confirmed all items in the freezer and refrigerator should be sealed and not exposed to air, and fruit should not have grey/green fuzz growing on it. [NAME] #178 further confirmed the sweet potatoes should be discarded. Observation at that time revealed [NAME] #178 picking up the box of sweet potatoes and several fruit flies flying from the box. [NAME] #178 confirmed fruit flies flew out of the sweet potato box. Observation on 10/25/23 at 9:11 A.M. revealed a tray of brownies uncovered on metal cart. On the shelf above the tray of brownies was an upside-down tray. There was a gap of approximately 3/4 to one inch between the brownie pan and the upside-down tray. The label on the brownie tray indicated they were made on 10/24/23 at 7:08 P.M. Interview on 10/25/23 at 9:34 A.M. with Dining Services Assistant Director (DSAD) #196 revealed the brownies were made on 10/24/23 for dinner on 10/25/23. DSAD #196 stated she was not aware how long the brownies had been sitting out. DSAD #196 confirmed the brownie pan was covered by the upside-down tray, but were not sealed or airtight. Review of the policy, Food Labeling and Dating Policy, revised 04/26/22 revealed all food items must be properly covered (not exposed to air) prior to being labeled and dated. 2. Observation on 10/25/23 beginning at approximately 7:23 A.M. revealed Dining Services Assistant Director (DSAD) #196 not wearing gloves while preparing fried chicken and scrambled eggs. DSAD #196 used her bare hands to pull two fry baskets of chicken out of the fryer, then spray the griddle with non-stick spray, then pour liquid eggs from a carton onto the griddle. DSAD #196 then cleaned a thermometer and used it to check the temperature of the chicken, and placed both fry baskets back into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 17 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 the oil. DSAD #196 then picked up a plate and used a spatula to remove the eggs from the griddle and put them on the plate. DSAD #196 then picked a piece of toast from the toaster with her bare hands and used her right hand to spread butter on the toast while she held it stable with her left hand. DSAD #196 then placed the toast on the plate with the eggs and gave it to the dietary aide to deliver to the resident. DSAD #196 identified the meal was for Resident #9. Residents Affected - Many Interview on 10/25/23 at 7:56 A.M. with DSAD #196 confirmed she used bare hands to touch the fryer, the thermometer, the spatula, and the ready-to-eat toast. DSAD #196 confirmed she should have washed her hands and put on gloves before touching the toast. Continued observation of DSAD #196 on 10/25/23 at approximately 8:13 A.M. revealed she washed some dishes in the dish machine, then used an electronic machine to create a label for storing food, then put on gloves without washing her hands. DSAD #196 then made toast for Resident #128 and held the toast with her gloved hands while buttering it and cutting the crust from his toast. Interview on 10/25/23 at 8:18 A.M. with DSAD #196 confirmed she did not wash her hands after doing dishes and touching the label making machine before putting on gloves to make Resident #128's toast. Observation on 10/25/23 at 9:25 A.M. revealed Dietary Aide (DA) #207 wearing gloves and assembling a breakfast plate for Resident #6. DA #207 touched a lid on the steam table, tongs for the bacon, and then held the toast with one gloved hand while buttering the toast with the other. Interview at that time with DA #207 revealed she was aware she touched non-food items before touching Resident #6's ready-to-eat toast. Review of the policy, Guideline for Handwashing/Hand Hygiene, revised 02/09/17 revealed staff should practice hand hygiene before and after preparing or serving meals. The policy provided no guidance regarding hand hygiene specific to kitchen staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 18 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy, and staff interview the facility failed to follow the protocols for the antibiotic stewardship. This affected one (Residents #44) of five residents reviewed for antibiotic stewardship. The current census is 80. Residents Affected - Few Findings include: Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 included diabetes, sleep apnea, lymphedema, presence of unigenital implants, urinary tract infections, and neuromuscular dysfunction of bladder. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, was incontinent of bowel and bladder, and was an extensive two-person assist with transfers. Further review of the MDS assessment revealed the resident had an indwelling catheter. Review of Resident #44's care plan dated 08/2023 revealed a focus for prophylactic antibiotic use related to recurrent urinary tract infections. Interventions included resident education regarding the risks of prophylactic antibiotics use. Review of Resident #44's physician orders dated 02/13/23 revealed an order for Resident #44 to receive Macrobid (antibiotics) 500 milligrams (mg). On 10/19/23 the resident was ordered to receive Ciprofloxacin (antibiotic) 500 mg twice a day until 10/25/23. Review of Resident #44's laboratory results for urine culture dated 10/19/23 revealed the culture isolated less than 10,000 colony forming units (CFU) mixed flora in specimen. Review of Resident #44's progress notes dated 10/19/2023 at 1:25 P.M. revealed Certified Nurse Practioner (CNP) #450 documented the resident was complaining of increased confusion, weakness, requiring help with eating, and a low grade temperature. Per the note the CNP ordered to a urine dip test and with results, started Ciprofloxacin antibiotic, orally 500 milligrams for 10 days. Per the note the CNP will adjust the antibiotic after the results of the culture and sensitivity test. Interview on 10/26/23 at 9:00 A.M. with Regional RN #444 verified after CNP #450 reviewed the results of the culture and sensitivity for Resident #44's urinary culture test the results did not indicate the resident had an urinary tract infection and the antibiotics were prescribed only based on the urine dip test. Interview on 10/26/23 at 11:20 A.M. with the Infection Control Preventionist (ICP) RN #222 revealed after reviewing the 10/19/23 results, Resident #44's infection did not require antibiotics per the guidelines followed in the antibiotic stewardship protocols. Interview on 10/26/23 at 11:20 A.M. with Certified Nurse Practioner (CNP) #450 verified the nursing staff have been instructed to obtain a urine 'dip test' prior to sending the sample to the laboratory for culture results. CNP #450 stated the facility's protocol is to follow the McGeer's protocol for antibiotics stewardship program, however, the CNP #450 verified she ordered oral antibiotics prior to knowing the final results of the culture and sensitivity for Resident #44. CNP #450 stated the antibiotics are reviewed after the results of the labs and discontinued or continued as appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366423 If continuation sheet Page 19 of 20 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete CNP #450 stated she as the provider felt Resident #44 was at increased risks for urinary tract infections. CNP #450 verified she did not follow the McGeer's protocols and prescribed oral antibiotics as soon as she receives the results of the abnormal urine dip tests for Resident #44. Review of the facility's undated antibiotic policy revealed for urinary tract infections any organism results must be greater than 10,000 CFU in the specimen to meet the criteria for antibiotics. Event ID: Facility ID: 366423 If continuation sheet Page 20 of 20