Health inspection·May 16, 2019

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident/resident representative of the facility's bed hold policy when a resident was transferred to the hospital. This affected one (#104) of four resident records reviewed for hospitalization. The census was 110. Findings include: Review of the medical record for Resident #104 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes, end stage renal disease, dependent on renal dialysis, anemia, coronary artery disease, and hypertension. Review of a progress note dated 03/01/19 at 12:53 P.M. revealed Resident #104's blood glucose level dropped while at a scheduled vascular center appointment. The resident was sent from the vascular center to the hospital for evaluation and treatment. Review of a progress note dated 03/01/19 at 4:40 P.M. revealed the resident was admitted to the hospital for low blood sugar. Documentation revealed the resident returned to the facility on [DATE]. Continued review of the progress notes revealed on 03/25/19 at 12:42 P.M. Resident #104 was sent from dialysis to the hospital for evaluation and treatment of a change in condition. Documentation revealed the resident was readmitted to the facility on [DATE]. Review of the medical record for Resident #104 revealed no documentation the resident/resident representative was notified of the facility's bed hold notice policy. Interview on 05/16/19 at 9:19 A.M. with Assistant Administrator (AA) #727 revealed a bed hold notice was not given to residents/resident representatives when a resident had an unplanned discharge to the hospital while at a scheduled appointment. AA #727 verified there was no bed hold notice given to Resident #104 or the resident's representative for the hospitalizations on 03/01/19 and 03/25/19 because the resident was not sent to the hospital by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 2 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 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 medical record review, observations and staff and resident interview, the facility failed to provide an individualized activity program designed to meet the interests and total care needs of Resident #61. This affected one (#61) out of two residents reviewed for activities. The facility census was 110. Residents Affected - Few Findings include: Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, aphasia, mix receptive expressive language, dysphagia oropharyngeal phase, hypertension, obesity, conduct disorder, cataract, contracture joint, abnormal posture, contracture: right hand, left hand, left elbow, right elbow, right knee, left ankle, right ankle, and heart failure, stiffness right shoulder neck and left should neck. Review of Resident #61's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident prefers listening to music, being around animals such as pets, doing things with groups of people, participating in favorite activities and participating in religious activities or practices. Further review of a quarterly MDS assessment dated [DATE] revealed the resident's cognition was impaired and the resident was totally dependent on staff for activity of daily living (ADL). Resident #61 has no clarity in speech, makes self-understood and rarely can understands others. Resident #61's vision is highly impaired with no corrective lens and the residents hearing is adequate. Review of Resident #61's care plan dated 08/16/18 revealed the resident liked to be out with neighbors, attend music or spiritual programs and watch television (TV) especially sports, aviation shows. Further review of a care plan conference held on 08/14/18 revealed Resident #61 enjoys being with others either watching TV especially sports or listening at an activity-music and spiritual. Resident #61 will smile and nod his head when excited about an activity. Staff is his family. Review of a care plan conference held on 04/16/19, revealed Resident #61 enjoys being with others, watching TV, listening to activities, attends Bible Study, listening to music and worship service. Staff is his family and are very attentive to him. Observations on 05/13/19 at 10:43 A.M., revealed Resident #61 was in bed fully clothed. Resident #61 was awake and had his eyes open; however he was not able to be interviewed due to his cognitive impairment. There was no TV, music or other individual activities being provided to Resident #61. Observation on 05/14/19 at 10:12 A.M., revealed Resident #61 was in bed fully clothed while activity occurring named Mingling Matters. Resident #61 was observed in laying in his bed in his room. Resident #61 was awake and had his eyes open. There was no TV, music or other individual activities being provided to Resident #61. Observation on 05/16/19 at 9:43 A.M., revealed Resident #61 was in bed fully clothed. Resident #61 was listening to a talk show on TV. Observation on 05/16/19 at 10:35 A.M. through 11:23 A.M., revealed Resident #61 was not participating in activity called Mingling Matters and Trivia. Resident #61 was observed in laying in his bed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 3 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 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 his room. Resident #61 was awake and had his eyes open. There was no TV, music or other individual activities being provided to Resident #61. Interview 05/16/19 2:23 P.M., revealed Activity Coordinator (AC) #931 reported resident does not like getting up early in the morning. AC #931 stated Resident #61 usually comes to activities when the State Tested Nursing Assistants (STNA's) brings him. During the interview the Resident #61's activity sheet was reviewed with AC #931. AC #931 verified the activity sheet she provided with Resident #61's participation is not totally accurate because Resident #61 was sometimes brought to different activities at the end of the activity; however, because he was there, AC #931 gave Resident #61 full credit for the entire activity. AC #931 confirmed Resident #61 was not provided activities in accordance with his preferences. Event ID: Facility ID: 365014 If continuation sheet Page 4 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to ensure one resident's bruise was documented in the medical record and monitored for changes affecting one (#44) out of four residents reviewed for non-pressure skin issues. Additionally, the facility failed to monitor a residents weights and input/output as ordered by the physician regarding a residents cardiac status affecting one (#1) out of 22 residents reviewed for appropriate care and services. The facility census was 110. Residents Affected - Few Findings include: 1. Review of Resident # 44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include type two diabetes mellitus, hypothyroidism and dementia without behavioral disturbance. The resident's minimum data set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living (ADL's) including bed mobility, transferring, dressing, eating, toilet use and personal hygiene. The medical record did not mention the resident had any bruising to her hands. The resident was not on anticoagulants. On 05/13/19 at 12:00 P.M. Resident #44 was observed in the dining room with a half dollar size bruise on top of her right hand. Resident #44 was cognitively impaired and unable to stay how she obtained the bruise. On 05/14/19 at 1:48 P.M. the resident was observed in a recliner in the common area in front of the nurses station. The resident had a half dollar size bruise on top of her right hand. During interview on 05/14/18 at 1:49 P.M. Registered Nurse (RN) #757 verified Resident # 44 had a bruise on the top of her right hand and stated the resident had a history of bruises to her hands and that the bruise was most likely from hitting her hand on her wheelchair or from the lift used to transfer the resident. RN #757 stated she was told of the resident's bruise over a week ago and verified it was not documented on the resident skin sheet or anywhere else in the medical record. RN #757 confirmed the resident's bruise should of been documented in the medical record and monitored. During interview on 05/15/19 at 10:58 A.M. RN/Nurse Manager #796 revealed she could not find a policy addressed the monitoring of bruises but stated the facility has always monitor them in the past. 2. Review of Resident #1's medical record review revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, recurrent syncope, hypertension, atrial fibrillation, coronary artery disease, and hyperlipidemia. Review of the MDS assessment dated [DATE] revealed Resident #1 was cognitively impaired, had no hallucinations, delusions, or behaviors during the review period. The resident is coded for an indwelling catheter, and as having had weight loss. Resident #1 is coded as receiving seven days of diuretic medication. Review of physician orders revealed the resident had an orders written on 04/05/19 for intake and output two times a day at 6:00 A.M. and 6:00 P.M. Additionally, the resident also had an order to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 5 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm weighed on Monday, Wednesday, and Friday upon arising, after toileting, prior to eating or drinking and with the same amount of clothes and no shoes on at 6:00 A.M. Staff are to notify cardiologist of weight gain of three pounds over two days or five pounds over seven days if no cardiologist on record notify primary care physician. Residents Affected - Few Review of Resident #1's intake and output report revealed it was incomplete every day of the month of May. Review of the Treatment Administration Record for May 2019 revealed the resident's weight was not documented as being obtained from 05/08/19 through 05/13/19. Review of progress notes revealed the notes are silent to a rationale for the resident not having a weight obtained on the above dates. Review of the residents' meal and weight report for the month of May 2019 revealed the resident had a weight obtained on 05/06/19 and again on 05/15/19 without any monitoring of weights in between these dates. During an interview with the Director of Nursing (DON) on 05/16/19 at 9:46 A.M. it was revealed the expectation is to record the entire amount of fluid a resident has in and out if a resident is ordered to have intake and output monitored. The DON verified the facility was not accurately documenting and recording Resident #1's intake and output, and the record was incomplete for the entire month of May 2019. During an interview with the DON on 05/16/19 at 10:50 A.M. it was verified the facility did not complete Resident #1's weights as per order. Resident #1 was not weighed by the facility from 05/06/19 through 05/15/19. The DON confirmed Resident #1 should have been weighed on 05/08/19, 05/10/19 and 05/13/19 and the facility had no documented weight for Resident #1 on those days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 6 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of an incident report, observation, staff interview and policy review, the facility failed to ensure Resident #88's fall interventions were implemented to prevent falls in accordance with the resident's fall risk care plan. This resulted in actual harm when Resident #88's call light was not within reach at the time the resident experienced a fall, the resident was subsequently hospitalized and required surgical intervention for a left hip fracture. In addition, the facility failed to ensure staff implemented a second resident's (#14) fall interventions in accordance with the care plan which did not result in injury. This affected two (#88 and #14) of two residents reviewed for falls and accidents. The facility census was 110. Findings include: 1. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with Lewy Bodies, dysphagia, hypertension, major depressive disorder and hyperlipidemia. Review of the care plan start dated 12/14/18, revealed Resident #88 was at risk for falls or injury related to Parkinson's disease with dementia. The goal of the care plan was to achieve optimal level of function in activities of daily living with progressive limitations of cognition. The approaches included to encourage the resident to use the call light for assistance, keep the call light in easy reach, and meet the residents needs promptly. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #88 had moderate cognitive impairment with a Brief Interview for Mental Status of 12 out of 15. The MDS assessment review further revealed the residents speech was clear, the resident was able to make self understood, and had the ability to understand others. Resident #88 required extensive assistance of one person for bed mobility, transfers, and toileting. Review of a fall risk assessment dated [DATE], revealed the resident's assessment score was 24. Further review of the fall risk assessment criteria revealed a score over nine indicates the resident is at risk for falls. Review of a nursing progress note dated 05/04/19 at 9:45 P.M. revealed Resident #88 was found on the floor and noted to have pain in the left hip. Review of the nursing progress note revealed the physician was notified of the fall and a new order was obtained to send the resident to the hospital for evaluation and treatment. Review of a nursing progress note dated 05/04/19 at 10:03 P.M. revealed Resident #88 was being admitted to the hospital for a left hip fracture. Review of an incident details report dated 05/04/19 revealed Resident #88 was found on the floor in his/her room on 05/04/19 at 6:30 P.M. The incident report further documented the resident was on the floor in front of his/her recliner chair. The recliner foot rest was elevated. Resident #88 reported to staff that he/she rolled off of the recliner chair and was having hip and foot pain. Continued review of the incident details report revealed Resident #88's left leg was observed to be short than the right leg and rotated inward. The incident report documented Resident #88's call lights were not within reach of the resident prior to the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 7 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 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 - Actual harm Residents Affected - Few Review of hospital documentation dated 05/04/19 at 10:38 P.M., revealed Resident #88 was brought to the hospital from the facility after the resident sustained a fall. Resident #88 reported to hospital staff he/she was attempting to get up from the recliner, the foot of the recliner would not go down, and the resident fell. The documentation further revealed radiograph (X-ray) results showed a left femoral neck fracture. The assessment and plan included a left hip fracture, orthopedic consultation and plan for surgery on Monday. Interview on 05/14/19 at 4:39 P.M. with Registered Nurse (RN) #900 revealed this nurse was in Resident #88's room to administer medication on 05/04/19 at approximately 6:20 P.M. RN #900 reported Resident #88 was in his/her recliner when the medications were administered. RN #900 reported on 05/04/19 at approximately 6:30 P.M. State Tested Nursing Assistant (STNA) #800 went to Resident #88's room and found the resident on the floor. RN #900 confirmed Resident #88 was at risk for falls and he/she was capable of using the call light. RN #900 further stated the staff provided Resident #88 with two call lights; however, upon further assessment after Resident #88's fall both call lights were observed on the residents pillow located on the resident's bed. RN #900 confirmed the call lights were not in reach of the resident when the resident was sitting in the recliner chair which is where Resident #88 fell. RN #900 revealed an investigation of the fall was completed. The investigation revealed the resident was not assisted in the recliner by facility staff and the call lights were not given to the resident because staff did not assist the resident to the chair. RN #900 verified on 05/04/19 at 6:20 P.M., 10 minutes prior to Resident #88 being found on the floor, RN #900 was in the residents room to administer medications and the resident was observed in the recliner chair at that time. RN #900 further verified Resident #88's call light placement was not checked by on 05/04/19 when she administered his/her medications because the resident appeared to be comfortable. Interview on 05/16/19 at 3:16 P.M. with STNA #800 revealed he/she entered Resident #88's room on 05/04/19 at 6:30 A.M. and the resident was observed sitting on the floor in front of his/her recliner chair. The foot rest of the recliner was elevated. STNA #800 stated Resident #88 had propelled himself/herself back to the room after supper. STNA #800 reported Resident #88 would sometimes transfer himself/herself, even though the resident required staff assistance for transfers. STNA #800 reported, Resident #88 was often given education from the staff for use of the call light and getting staff assistance for transfers. STNA #88 revealed Resident #88 had two call lights in his/her room but could not verify the location of either call light at the time of the fall. STNA #88 revealed when the resident was observed sitting on the floor, the STNA immediately went to notify the nurse and did not check for call light placement. 2. Review of medical records revealed Resident #14's was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral, Alzheimer's disease, hypertension, depression, history of falling, abnormalities of gait and mobility, pain in right knee, pain left knee, and unspecified fall. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 has severe impaired and requires supervision for activities of daily living. Resident #14 also required limited assistance for dressing. The at risk for falls care plan dated 06/08/18 documented Resident #14 is always to wear non-skid socks and shoes. Review of a fall risk assessment dated [DATE] identified Resident #14 scored an 11 indicating the resident was at risk for falls. Observation on 05/15/19 at 2:09 P.M., revealed Resident #14 sleeping in bed. Bed was low and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 8 of 9 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 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 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 - Actual harm Residents Affected - Few against the wall as in the care plan. Resident #14 had no nonskid socks on her feet. Resident #14 shoes were under the bed, her walker was about two feet away from bed. The call light was not in reach. Call light was about four feet away. Interview on 05/15/19 at 2:47 P.M., revealed Licensed Practical Nurse (LPN) #707 reported the State Tested Nursing Assistants (STNA's) lay out clothes for Resident #14 to wear. LPN #707 stated Resident #14 requires limited assistance getting dressed. Resident #14 goes to the bathroom without any assistance. Interview on 05/15/19 at 2:49 P.M., revealed STNA #863 verified Resident #14 did not have on nonskid socks but second shift makes sure resident has on nonskid socks. Reviewed policy titled Brethren Retirement Community Falls and Fall Risk, Managing revised December 2007 states based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 9 of 9