Health inspection·June 13, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to ensure staff used gloves and performed hand washing as appropriate. This affected 13 (Residents #3, #6, #9, #10, #12, #19, #23, #25, #32, #39, #40, #255, and #256) of 13 residents who receive meals on the fifth floor. The census was 63. Finds include: During observation of meal service on the fifth floor on 06/08/22 at 11:45 A.M., Dietary Aide #254 cleaned his hands and put on gloves. He started serving meals. Without removing his gloves, he went out to the dining room, retrieved items from the refrigerator and got coffee and other drinks for residents. He came back into the serving area. He did not change his gloves or wash his hands after reentering the serving area. During interview at the time of the observation, Dietary Aide #254 stated he puts gloves on and they are on for the duration of meal service. He does not touch the food. He goes to the dumbwaiter when the special foods come up, or helping out the staff with delivering drinks in between plating food. During interview on on 06/08/22 at 12:30 P.M., Dietary Manager #255 verified Dietary Aide #254 should have taken off his gloves and washed his hands then put on new gloves after touching anything which is not food related. Review of the policy titled Glove Use, dated 04/02/19, revealed gloves will be available for use and will be worn to maintain safe and sanitary food service. Change gloves whenever you change activity, the type of food being worked with or whenever you leave the work station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 2 of 4 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 06/13/2022 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the COVID-19 staff vaccination status, review of staffing schedules, review of the list of COVID positive resident, staff interview, and review of the facility policy; the facility failed to ensure the staff COVID-19 vaccination rate was 100%. This had the potential to affect all 63 residents who resided in the facility. The census was 63. Residents Affected - Many Findings include: Review of the undated facility COVID-19 staff vaccination status revealed the facility had a total of 160 employees. There were 117 employees fully vaccinated for COVID-19, 41 employees with exemptions and two employees who were not vaccinated for COVID-19 and did not have an exemption. The staff vaccination rate was 98.8 percent. Review of the list of partially vaccinated staff revealed that Licensed Practical Nurse (LPN) #114 and Dietary Aide #256 received only one dose of a two-dose vaccine. Review of the facility's undated list of COVID positive residents revealed there had not been any residents diagnosed with COVID-19 in the past four weeks. During interview on 06/09/22 at 3:40 P.M., the Administrator verified the facility had a 98.8 percent staff vaccination rate. The Administrator verified LPN #114 and Dietary Aide #256 were not vaccinated for COVID-19, did not have a religious or medical exemption and were reporting to work to provide direct resident care. The Administrator revealed employees who were not vaccinated and did not have an exemption for COVID-19 were expected to test twice a week. Review of the policy titled COVID-19 Staff Vaccine Mandate dated 06/09/22, revealed the facility required all staff to be fully vaccinated against COVID-19 in accordance with the Centers for Medicare and Medicaid Services' COVID-19 rules (Vaccine Mandate). Fully Vaccinated means it has been two weeks since the individual completed a primary vaccination series for COVID-19. Documentation of Vaccination Status means documentation that includes, as applicable: (i) whether an individual is Fully Vaccinated, in the process of becoming Fully Vaccinated, or exempt from vaccination; (ii) proof of vaccination; (iii) the date vaccination dose(s) were administered, including booster dose(s); (iv) requests for exemption and related information; (v) approval or denial of exemption requests; (vi) information relating to any delay of vaccination; and (vii) precautions to be followed by unvaccinated staff. Procedure: 1. Vaccine Requirements. Staff will not be permitted to provide care, treatment, or other services for BRC and/or its residents unless they meet the following requirements: A. All Staff hired or engaged before December 6,2021 must have received, at a minimum, the first dose of a primary series or a single dose COVID-19 vaccine by December 5, 2021. B. All staff hired or engaged before December 6, 2021 must be fully vaccinated against COVID-19 by January 4,2022. Individuals will be considered fully vaccinated if they have received all doses of their vaccination series by January 4, 2022, even if they have not yet completed the 14-day waiting period required for full vaccination. C. All staff hired or engaged after December 6, 2021 must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents. If the individual opts to use a two-dose COVID-19 vaccination, they must promptly complete the two-dose COVID-19 vaccination consistent with guidelines established by the manufacturer and/or the CDC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 3 of 4 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 06/13/2022 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 0888 Level of Harm - Minimal harm or potential for actual harm Review of Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-22-09-ALL regarding COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365014 If continuation sheet Page 4 of 4