Health inspection·October 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intervention included a bed alarm. This is not documented on care plan for 07/30/25. Review of the progress note dated 08/08/25 at 10:48 P.M. revealed that Certified Nursing Aide (CNA) was assisting the resident from the bathroom back to bed, the resident lost his footing and tripped over his feet, the CNA lowered the resident to floor. The resident was assessed with no injuries or pain. The resident was assisted back to bed call light in reach and bed in low position. Medical doctor and family notified. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 08/08/25 found resident fell while being assisted by staff. The investigation reported he tripped over his feet but did not specify how that occurred and what footwear was in place. The new intervention included educating the resident to turn and change positions slowly. Review of the progress note dated 08/20/25 revealed the bed and chair alarm were discontinued after a nursing assessment found resident was able to demonstrate safe transfers without the need for alarms. Visual reminders were placed in his room to remind Resident #5 to use the call light. Review of the progress note dated 08/20/25 at 3:30 P.M. revealed the resident was observed on bathroom floor by a certified nursing aide. Resident #5 was assessed and found two abrasions. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 08/20/25 found resident had an unwitnessed fall in the bathroom. The investigation did not include information about the last time resident had been toileted or went to the bathroom. The new intervention included educating the resident on use of the call light. Review of the progress note dated 08/20/25 at 11:45 P.M. revealed the resident was found on floor laying on his left side by the shower floor. The resident stated he was heading to the bathroom at the time of the fall. The resident was transferred to the emergency department due to vital sign changes and changes in mental status upon assessment. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 08/20/25 found resident had an unwitnessed fall in the bathroom and was found lying by the shower. The investigation did not include any mention of last time resident was assisted to the bathroom and/or was toileted. The new intervention included resident transfer to the hospital and for evaluation due to concerning vitals and began using the bed and chair alarms again. No interventions mentioned toileting or anything related to use of the bathroom after two falls this date in the bathroom. Review of the progress notes dated 08/26/25 at 8:21 A.M. and at 2:44 P.M. revealed the interdisciplinary team discussed the falls from 08/20/25 and added frequent visualization of resident and re-added bed and chair alarms. Review of the progress note dated 08/29/25 at 2:00 P.M. revealed the resident was found on his back in his room, resident unable to state what happened at the time of the fall. Resident had a small laceration on his head and left shoulder. The new intervention including resident was moved to a room closer to the nursing station to improve safety checks. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 08/29/25 revealed staff found resident laying on the floor. Resident could not provide details of what had caused the fall. The new intervention included moving resident's room closer to the nursing station. Review of the progress note dated 09/11/25 at 6:10 A.M. revealed the Certified Nursing Aide (CNA) went to answer the bed alarm and found resident kneeling beside his bed on his right knee. It was mentioned in the note that the resident was not wearing grip socks at the time of the fall. The new intervention included the resident was educated on using the call light when needing to ambulate. Review of the progress note dated 09/11/25 at 3:39 P.M. revealed the IDT team revealed non-skid socks were added for fall intervention. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/11/25 revealed staff found resident kneeling near the bed. The new intervention included educating the resident to use the call light and for the resident to wear non-skid socks. Review of the progress note dated 09/14/25 at 3:28 A.M. revealed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 725004 If continuation sheet Page 2 of 7 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 725004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Marion Health and Rehabilitation The 155 Marion Cardington Road West Marion, OH 43302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few while walking with a CNA with his walker, with a clear path to the bathroom, the resident became weak and dropped to the floor. On 09/14/25 at 3:45 A.M. stated during a routine check, the resident was difficult to arouse and would not stay awake long, so staff contacted the medical team, and resident was transferred to hospital. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/14/25 revealed staff was walking with the resident and staff to the bathroom, and his legs became weak and gave out. The resident was lowered to the floor by staff and found to have low blood pressure. The new intervention included when ambulating with the resident with his walker, a wheelchair shall follow behind resident. Review of the progress note dated 09/18/25 at 4:27 P.M. from the IDT note revealed a new intervention for staff to follow behind the resident in wheelchair. Review of the progress note dated 09/21/25 at 12:00 P.M. revealed staff observed the resident attempting to stand from bed in lowest position then slide to the floor. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/21/25 revealed staff entered the room while the resident was sitting at the edge of the bed. The resident attempted to stand and slid to the floor. The new intervention included non-slip strips to be added to both sides of the bed. Review of the progress note dated 09/21/25 at 10:41 P.M. revealed the resident was lowered to floor while walking back from bathroom. Staff were with the resident at the time of the fall and called out for assistance as they lowered the resident to the ground. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/21/25 revealed the resident was in the bathroom along with staff. While walking back from the bathroom the resident's legs gave out and the resident was lowered to the floor. The new intervention included staff training to use the wheelchair to follow behind resident during ambulation with the walker. The investigation stated all interventions were in place and effective, yet the new intervention was to educate the staff on the interventions of using the wheelchair behind the resident when ambulating. Review of the progress note dated 09/22/25 at 7:30 A.M. revealed the resident was observed on knees by his bed. Resident #5 stated he was trying to get to the bathroom. Resident and staff educated on needing two people to get resident up and having wheelchair and staff behind resident when ambulating. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/22/25 revealed resident was attempting to get to the bathroom when he fell. The new intervention included staff education on using two-person assist, following behind in the wheelchair, and offer toileting at regular intervals to avoid attempts. This fall was documented as unwitnessed. Review of the progress note dated 09/22/25 at 6:30 P.M. revealed the resident was found on the floor in the hallway just outside his door with his tube feed pole at the end of his feet. The PEG (feeding) tube had completely dislodged from his abdomen and was also laying on the floor. The resident was transferred to the hospital to have the PEG tube replaced. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/22/25 revealed staff found resident after a fall in the hallways where his tube feed was dislodged. The new intervention included hip protectors to prevent injuries from falls. Review of the progress note dated 09/29/25 at 3:31 A.M. revealed the resident rolled out of bed onto the floor onto his knees. The resident had a skin tear to his elbow. Review of the progress note dated 09/29/25 at 12:04 P.M. of IDT fall review revealed a new intervention of hip protectors. Another progress note dated 09/29/25 time at 12:06 P.M. revealed new interventions of a communication board (to assist with resident communication) and medication review. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/29/25 revealed staff found resident had rolled out of bed onto his knees and had skin tear. The new intervention included use of a communication board and medication review. Review of the progress note dated 09/29/25 at 6:01 P.M. revealed the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 725004 If continuation sheet Page 3 of 7 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 725004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Marion Health and Rehabilitation The 155 Marion Cardington Road West Marion, OH 43302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was found on the bathroom floor after he was walking without assistance. The resident continued to be non-compliant and social services and nursing staff had discussions about hospice care which the resident declined. A new intervention of bed in lowest position was added to the care plan. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/29/25 revealed staff found resident on the bathroom floor. The new intervention included ensure bed was in lowest position. Review of the progress note dated 09/30/25 at 9:00 A.M. revealed the resident was seen sliding out of bed onto his knees on the floor. The new intervention was for floor mats (to protect from injury during fall) to be added to both sides of the bed. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 09/30/25 revealed staff witnessed the resident slide out of bed. The new intervention included floor mats on the sides of the bed. Review of the progress note dated 10/02/25 at 3:00 P.M. of the IDT fall review from 09/29/25 revealed a new intervention of bed in low position. Review of the progress note dated 10/04/25 at 2:10 P.M. revealed the resident was found kneeling on floor beside bed. Review of fall risk investigation and interdisciplinary team (IDT) fall investigation dated 10/04/25 revealed staff found resident kneeling beside the bed. The new intervention included to offer to assist with ambulation with a walker and gait belt. Review of the progress note dated 10/08/25 at 9:41 A.M. of the IDT fall review from 10/04/25 revealed a new intervention to offer assistance in walking with a gait belt. Interview on 10/08/25 from 4:45 to 5:20 P.M. with the Administrator and the Director of Nursing confirmed Resident #5 had many falls. They confirmed there were no witness statements obtained for the two witnessed falls on 09/21/25 and a witnessed fall on 09/30/25 and unwitnessed falls on 07/30/25, 08/20/25, 08/29/25, 09/11/25, two falls on 09/22/25, 09/29/25 and 10/04/25. The DON reported the fall investigation contained the facilities root cause analysis and events of the fall. The DON reported facility felt interventions were appropriate. For the fall on 07/30/25, the DON confirmed Resident #5 was found on the bedroom floor. The new intervention, due to resident being a new admit was for a bed alarm to be put in place. For the fall on 08/08/25, the DON confirmed this was a fall that occurred while staff were ambulating resident and he tripped. The DON acknowledged the investigation made no mention of what footwear Resident #5 was wearing, if it was slippery, and how many staff were assisting Resident #5. The DON confirmed staff did not initiate any interventions related to assistance when transferring. She reported the fall was due to low blood pressure when was not mentioned in any progress notes or in the fall investigation, then stated resident's intervention of turning and changing positions slowly was appropriate due to jerking motions which was also not mentioned in any documentation or in the investigation related to the fall. For the two falls on 08/20/25, the DON confirmed both times resident was found in the bathroom on the floor. The DON confirmed the intervention was appropriate for staff education on using the call light and restarting the bed and chair alarms, which had been discontinued earlier that day. The DON and the Administrator were unable to provide details of any interventions related to toileting prior to the two falls in the bathroom on the same day. The DON reported Resident #5's wife had wanted to bed and chair alarms discontinued and agreed facility had no evidence of this request from resident or family. For the fall on 08/29/25, the DON confirmed the resident was found on the floor in his room and the resident was moved closer to the nursing station. For the fall on 09/11/25, the DON confirmed resident was found on the floor in his room and was again educated on using the call light and wearing non-skid socks. The DON and the Administrator confirmed they would educate after each fall to use the call light. For the fall on 09/14/25, the DON confirmed this fall occurred while staff were ambulating the resident to the bathroom. The DON confirmed the new intervention was to follow behind with a wheelchair when ambulating with a walker. For the two falls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 725004 If continuation sheet Page 4 of 7 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 725004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Marion Health and Rehabilitation The 155 Marion Cardington Road West Marion, OH 43302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 09/21/25, the DON confirmed both were witnessed. The resident was seen sliding off the bed and a second fall the resident was being assisted by staff from the bathroom when his legs gave out. The DON confirmed non-skid strips were added to the sides of the bed and staff were educated to follow behind resident with a wheelchair when ambulating. The DON confirmed the investigation was documented yes when asked if interventions were in place and effective. The DON also confirmed staff did not follow behind resident with a wheelchair as per the care plan for the 09/21/25 fall. The DON confirmed the investigation did not state any failure of staff to follow interventions and confirmed the investigation was inaccurate in stating interventions were in place and effective at the time of the fall. Facility was unable to provide evidence of staff statements related to either fall. For the two falls on 09/22/25, the DON confirmed the resident was found lying in the hallway with an intervention of hip protectors and second fall where resident was found kneeling on the floor beside his bed with the new interventions included educating staff on using two-person assistance, use of the wheelchair following behind resident, and offer toileting at regular intervals. The DON reported she was unsure why the interventions of following behind in the wheelchair and two-person assist were added as it was an unwitnessed fall. She stated it must have been an error. For the two falls on 09/29/25, the DON confirmed the resident was found on the bathroom floor with intervention to have bed in lowest position. DON confirmed facility already had progress notes stating bed was in low/lowest position. The DON confirmed the second fall revealed that resident rolled out of bed onto his knees and confirmed the intervention of a communication board and medication review were completed. The DON acknowledged the communication board was already in place and had been documented in previous notes. Progress notes for the fall on 09/30/25, the DON confirmed a witnessed fall where resident was seen sliding out of bed onto his knees. The DON confirmed the new intervention put in place was for floor mats to each side of the bed. She also acknowledged the non-slip strips were likely no longer appropriate due to placing floor mats over the non-slip strips. Facility had no evidence of any staff statements related to this fall. Interviews on 10/09/25 from 11:00 A.M. to 1:00 P.M. with Regional Registered Nurse (RN) #200 revealed staff should not be documenting interventions were in place if they were not or were unable to be followed for whatever reason. The RRN also verified no interventions were put in place related to toileting until 09/22/25 after 10 falls several of which were in the bathroom or on the way to the bathroom. The RRN reported facility added increased supervision and offering toileting at intervals and confirmed facility had no documentation of how frequently or how often these should be. She stated staff should look in his room anytime they pass by the room. Confirmed investigations did not include staff statements for all witness falls. RRN agreed interventions could be more specific and stated resident should be educated to use the call light after each fall (regardless of appropriate cognition). She confirmed staff did not follow behind resident with the wheelchair as per the care plan, yet the investigation stated all interventions were appropriate and effective. Stated the interventions were decided on by an interdisciplinary team and they can choose whatever they deem necessary. 2. Review of the medical record for Resident #28 revealed an admission date of 08/23/25. Diagnoses included cerebral infarction, cerebrovascular disease, spinal stenosis and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition and required substantial maximum assistance for activities of daily living. Review progress notes dated 09/04/25 at 8:36 P.M. revealed the resident was found on the floor and informed staff he wanted to walk to the bathroom. The resident was informed he needed two fully functioning legs to do that. and was assisted with a gait belt along with three staff back to bed. Review of the fall risk investigation dated 09/04/25 at 8:05 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 725004 If continuation sheet Page 5 of 7 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 725004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Marion Health and Rehabilitation The 155 Marion Cardington Road West Marion, OH 43302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed the resident had a fall in his room. The investigation stated staff were helping resident to the bathroom when he slid off the recliner. Resident reported he had lost his balance and slid to the floor. No new intervention was identified. Review of the plan of care dated 09/05/25 revealed resident was at risk of falls with interventions for stand by assist during oral care, ensure environment was free of clutter, bed alarm, ensure call light was in reach, maintain a clear pathway, and have commonly used items in reach. Review of progress note dated 09/05/25 at 9:00 P.M. revealed status post recent fall, the resident appears stable with neuro checks within normal limits. Review of the fall interdisciplinary investigation dated 09/04/25 (reported as misdated from 09/05/25) at 1:00 A.M. revealed resident had a fall in their room after attempting to get up out of bed to get clothes out of his closet when staff walked in. The fall investigation stated resident was trying to get clothes to get dressed. The intervention put in place included a bed alarm. Review of the fall risk investigation dated 09/05/25 at 1:00 A.M. revealed the resident had a fall in his room. The investigation stated the resident was attempting to get out of bed to get clothes out of the closet when staff walked in, they assisted resident to the floor. No new intervention was identified. Review of neuro checks dated 09/05/25 revealed they began at 1:00 A.M. when they fall occurred. Staff were supposed to complete four 15-minute checks, four 30-minute checks, four one-hour checks, four four-hour checks, four eight-hour checks. The 15-minute checks included 09/05/25 at 1:18 A.M., 1:35 A.M., and 1:49 A.M. The 30-minute checks included 09/05/25 at 2:15 A.M., 2:47 A.M., 3:20 A.M., and 3:52 A.M. The hour-checks included 09/05/25 at 4:06 A.M., 5:09 A.M. There was no neuro checks documented between 5:09 A.M. to 9:09 P.M., a 16-hour time span. Four-hour checks included 09/05/25 at 9:09 P.M., and 09/06/25 at 1:00 A.M., 5:00 A.M. Eight-hour checks included 09/06/25 at 1:00 P.M., and 8:00 P.M. and 09/07/25 at 4:00 A.M., 8:00 A.M., 4:00 P.M. and 09/08/25 at 12:00 A.M. and 8:00 A.M. Review of the medical record also found no evidence of progress notes from any fall on 09/10/25. Progress note dated 09/11/25 at 4:27 A.M. revealed resident was status post fall on 09/10/25. The resident stated 0/10 level for pain. Review of incident accident log revealed one fall on 09/05/25 and no fall was listed from 09/10/25. Interview on 10/09/25 from 11:00 A.M. to 11:10 A.M. with the Administrator revealed no knowledge of additional neuro checks as he provided the same ones as already provided for survey review. The Administrator verified there were no neuro checks documented between 5:09 A.M. to 9:09 P.M., a 16-hour time span. Interviews on 10/09/25 from 11:53 A.M. to 1:00 P.M. with Regional Registered Nurse (RRN) #200 confirmed facility had a progress note from 09/04/25 at 8:05 P.M. fall stating resident was found on the floor and the investigation risk assessment stated Resident #28 was being assisted at the time of the fall. She confirmed the conflicting information of fall being witnessed verse unwitnessed. She confirmed facility had no evidence of a fall interdisciplinary investigation being completed. The RRN also confirmed facility had no evidence of progress notes documenting Resident #28's fall on 09/05 at 1:00 A.M. She also confirmed only one of the three falls mentioned were documented on the incident accident log. RRN reported facility did not believe a fall occurred on 09/10 for Resident #28 and believed the nurse was documenting from the note on 09/10 about resident attempting to get out of bed and was redirected. She believed it was mis documented but had no evidence related to progress note and no evidence of neuro checks as progress note indicated. She confirmed the note stated neurochecks were complete and within normal which facility had no evidence of neuro checks being completed. Interview on 10/09/25 at 1:30 P.M. with Administrator, Director of Nursing and Assistant Director of Nursing confirmed neuro checks were not done according to timed instructions. Review of the policy titled, Fall Management dated 10/17/16 revealed facility shall assess, develop and implement care plans with ongoing monitoring and review for falls. An interdisciplinary (IDT) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 725004 If continuation sheet Page 6 of 7 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 725004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Marion Health and Rehabilitation The 155 Marion Cardington Road West Marion, OH 43302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete care plan shall be developed to reflect needs and interventions and updated as needed. New fall interventions shall be communicated to caregivers as needed. The IDT team shall determine the need for development of additional interventions or follow- up measures that were needed to reduce the risk of falls. The fall policy did not include any language related to fall investigations except the charge nurse shall gather information related to the fall. This deficiency represents non-compliance investigated under Complaint Number 2626292. Event ID: Facility ID: 725004 If continuation sheet Page 7 of 7