Inspection·June 6, 2022

F 0569 the responsible party when funds exceed $1,800. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 2 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on patient trust account review, surety bond review, policy review, and staff interviews, the facility failed to ensure the surety bond covered the total balance of resident funds. This had the potential to affect 23 of 23 residents who had their funds handled by the facility. The facility census was 48. Residents Affected - Some Findings include: Interview with the Director of Nursing for entrance conference on 05/31/22 at 9:35 A.M., revealed the surveyors need a copy of the surety bond and all resident funds with their total balances. Review of the funds balance dated 05/27/22 on 06/02/22 revealed the balance of the residents facility accounts was $37,042.43. There was 23 resident accounts listed. Review of the facility surety bond on 06/02/22 revealed the bond was increased from $35,000 to $50,000 on 06/01/22. Interview with the Administrator on 06/02/22 at 11:53 A.M., verified the funds have been over the amount of the $35,000 surety bond amount and she noticed it on 06/01/22 and got the surety bond increased to $50,000. Review of the monthly funds balance report from 01/31/22 to present revealed the resident funds account was over the surety bond amount of $35,000 since at least 01/31/22 with a monthly balance as high as $49,739.45. Review of the policy titled Surety Bond dated 01/01/22, revealed the facility is responsible to make sure the surety bond amount exceeds the amount in resident trust fund. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 3 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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, Beneficiary Notice- Residents discharged list review, and staff interview, the facility failed to inform the resident or his or her legal representative in writing that Medicare will not pay for covered skilled services, and why these specific services may not be covered and the potential liability for payment for the non-covered services. This affected three (#30, #97, and #98) of three residents reviewed for beneficiary notices. The facility census was 48. Residents Affected - Some Findings include: 1. Review of Resident #30's medical record revealed an admission date of 03/17/21. Diagnoses included chronic peripheral venous insufficiency, gastro-esophageal reflux, personal history venous thrombosis and embolism, osteoarthritis, lack of physical excercise, and weakness. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent on two staff for bed mobility and transfers, dependent on one person for toileting, and supervision for eating. Review of the Beneficiary Notice- Residents discharged list within the last six months on 06/01/22 revealed Resident #30 was discharged from skilled services on 12/21/21 and remained in the facility. Review of Resident #30's Physician Orders dated 12/10/21 revealed on 12/08/21 he was to start skilled services for COVID-19. Interview with the Administrator on 06/02/22 at 12:20 P.M., verified she did not have any beneficiary notices for Resident #30 including Notice to Medicare Provider Non-coverage (NOMNC) form CMS-10123, and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form CMS-10055. 2. Review of Resident #97's medical record revealed an admission date of 12/0/21 and a discharge on [DATE]. Diagnosis included: COVID-19, major depressive disorder, hypertension, and chronic obstructive pulmonary disease. Review of the Beneficiary Notice- Residents discharged list within the last six months on 06/01/22 revealed Resident #97 was discharged from skilled services on 02/13/22 and discharged from the facility that day. Review of Resident #97's Physician Orders dated 01/27/22 revealed she was to start skilled services for COVID-19 on 01/27/22. Interview with the Administrator on 06/02/22 at 12:20 P.M. verified she did not have any beneficiary notices for Resident #97 including Notice to Medicare Provider Non-coverage (NOMNC) form CMS-10123. 3. Review of Resident #98's medical record revealed an admission date of 02/08/22 and a discharge on [DATE]. Diagnosis included: COVID-19, anemia, and post traumatic stress disorder. Review of the Beneficiary Notice- Residents discharged list within the last six months on 06/01/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 4 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0582 Level of Harm - Minimal harm or potential for actual harm revealed Resident #98 was discharged from skilled services on 02/14/22 and discharged from the facility that day. Review of Resident #98 Progress Notes dated 02/09/22 revealed he was receiving skilled services for COVID-19 on 02/08/22. Residents Affected - Some Interview with the Administrator on 06/02/22 at 12:20 P.M., verified she did not have any beneficiary notices for Resident #98 including Notice to Medicare Provider Non-coverage (NOMNC) form CMS-10123. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 5 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0584 Level of Harm - Potential for minimal harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, staff interviews, and review of facility's policy, the facility failed to ensure the use of overhead paging was for only emergency situations. This had the potential to affect all 48 residents residing in the facility. Findings include: Observation on 05/31/22 at 11:22 A.M. revealed the overhead paging system was utilized by staff to announce meal trays were being ready for delivery. Interview on 05/31/22 at 11:22 A.M. with Certified Nursing Assistant (CNA) #20 verified the overhead paging system had been used by staff in the kitchen to announce meal trays being ready for delivery. Observation on 05/31/22 at 3:45 P.M. revealed the facility overhead paging system was utilized by staff to announce a phone call for an employee. Observation on 06/02/22 at 7:10 A.M. revealed the overhead paging system was utilized by staff to announce meal trays being ready for delivery. Interview with CNA #15 on 06/02/22 at 7:15 A.M. verified the overhead paging system was utilized by kitchen staff to announce meal trays being ready for delivery at every meal. Review of the facility's policy titled Noise Control, revised 04/2014, revealed paging systems shall not be used except in emergency situations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 6 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the ombudsmen of a resident's discharge from the facility. This affected one (#28) of two residents reviewed for hospitalization. The facility census was 48. Findings include: Review of the medical record for Resident #28 revealed an admission of 04/11/11, with diagnoses including transient ischemic attack, bipolar disorder, schizoaffective disorder, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require one-person extensive assistance with transfers, dressing, toileting, and bathing, and supervision in eating. Review of the progress note dated 03/24/22 at 3:45 P.M., revealed Resident #28 had edema and redness to left lower extremity and redness and warmth to right lower extremity as well as pain. Physician was notified and gave orders to send to the emergency room. A voicemail was left for power of attorney (POA) to return call to the facility. Review of the progress note dated 03/24/22 at 7:00 P.M., revealed Resident #28's POA returned call to the facility and updated on Resident #28's condition. Review of the progress note dated 04/27/22 at 3:00 P.M., revealed Resident #28 had right facial drooping, tongue deviation, and slurred speech. Physician was notified and received an order to send to the emergency room via squad. The family was aware. Further review of the medical record revealed no evidence of the ombudsmen being notified of Resident #28 transferring to the hospital on [DATE] and 04/27/22. Review of the transfer/discharge notification log dated March 2022 revealed Resident #28 was not listed in the log for notification to the Ombudsmen for hospitalization on 03/24/22. Review of the transfer/discharge notification log dated April 2022 revealed Resident #28 was not listed in the log for notification to the Ombudsmen for hospitalization on 04/27/22. Interview on 06/02/22 at 11:03 A.M., with Regional Clinical Director of Operations #400 revealed notifications to the Ombudsmen had not been completed for Resident #28 for his hospitalization on 03/24/22 or 04/27/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 7 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 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 record review, staff interview, and policy review, the facility failed to provide bed hold notices to residents/resident representatives within 24-hours of transferring to the hospital. This affected two (#10 and #28) of two residents reviewed for hospitalization. The facility census was 48. Findings include: 1. Review of the medical record of Resident #10 revealed an admission date of 06/08/20. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. The resident transferred to the hospital again on 05/07/22 and returned to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, repeated falls, lack of coordination, osteoarthritis, abnormal posture, attention and concentration deficit, conversion disorder with seizures or convulsions, gastro-esophageal reflux disease, and major depressive disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident exhibited fluctuating inattention and altered level of consciousness during the assessment period. The resident required extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfers, limited assistance for eating, and was totally dependent for toileting. Review of Resident #10's medical record revealed no evidence of Resident #10's responsible party being notified of the facility policy for bed hold. Interview on 06/02/22 at 11:04 A.M., the Regional Director of Clinical Operations (RDCO) #400, verified Resident #10's responsible party was not notified of the facility bed hold policy. Review of the undated policy titled, Bed Holds and Returns, revealed, prior to transfers, residents or resident representatives will be informed in writing of the bed hold and return policy. 2. Review of the medical record for Resident #28 revealed an admission date of 04/11/11, with diagnoses including transient ischemic attack, bipolar disorder, schizoaffective disorder, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require one-person extensive assistance with transfers, dressing, toileting, and bathing, and supervision in eating. Review of the progress note dated 03/24/22 at 3:45 P.M., revealed Resident #28 had edema and redness to left lower extremity and redness and warmth to right lower extremity as well as pain. Physician was notified and gave orders to send to the emergency room. A voicemail was left for power of attorney (POA) to return call to the facility. Review of the progress note dated 03/24/22 at 7:00 P.M., revealed Resident #28's POA returned call to the facility and updated on Resident #28's condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 8 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 04/27/22 at 3:00 P.M., revealed Resident #28 had right facial drooping, tongue deviation, and slurred speech. Physician was notified and received an order to send to the emergency room via squad. Family aware. Review of the medical record revealed there was no bed hold notice given to Resident #28 for hospitalizations on 03/24/22 and 04/27/22. Interview on 06/02/22 at 11:03 A.M., with Regional Clinical Director of Operations #400, revealed bed hold notifications had not been completed for Resident #28 for his hospitalization on 03/24/22 or 04/27/22. Review of the undated policy titled, Bed-Holds and Returns, revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outline in this policy. The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 9 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy reviews, the facility failed to ensure a resident was lifted in a safe manner in order to prevent potential injury. The facility also failed to ensure fall interventions were implemented. This affected one (#10) of two reviewed for accidents. The facility census was 48. Findings include: Review of the medical record of Resident #10 revealed an admission date of 06/08/20. Diagnoses included dementia without behavioral disturbance, repeated falls, lack of coordination, osteoarthritis, abnormal posture, attention and concentration deficit, conversion disorder with seizures or convulsions, gastro-esophageal reflux disease, and major depressive disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident exhibited fluctuating inattention and altered level of consciousness during the assessment period. The resident required extensive assistance of one staff for bed mobility, extensive assistance of two staff for transfers, limited assistance for eating, and was totally dependent for toileting. Review of the care plan dated 06/22/20 revealed the resident was at risk for potential injury related to poor safety awareness, confusion, deconditioning, history of falls, dementia, and diuretic use. Interventions included a dycem to wheelchair. Review of current physician orders revealed an order for a pressure reducing cushion to the wheelchair with a dycem on the cushion. Observation on 06/02/22 at 9:20 A.M., revealed Certified Nursing Assistant (CNA) #50 and Medical Records (MR) #11 lifted Resident #10 from her wheelchair to a standing position by placing their arms under the resident's arms. There was no dycem observed on top of the cushion in Resident #10's wheelchair. CNA #50 and MR #11 then sat Resident #10 back down in her wheelchair. A gait belt was not used at any point when CNA #50 and MR #11 lifted Resident #10 up from her chair and sat her back down. Interview on 06/02/22 at 9:21 A.M., with CNA #50 and MR #11 verified Resident #10 was lifted underneath each arm and a gait belt was not used when they lifted Resident #10. CNA #50 and MR #11 further verified there was no dycem present on the cushion in the wheelchair under the resident. Interview on 06/02/22 at 9:34 A.M., Licensed Practical Nurse (LPN) Supervisor #14 verified lifting Resident #10 by the arms instead of using a gait belt was not an appropriate method of lifting the resident. Review of the undated policy titled, Managing Falls and Fall Risk, revealed the staff will identify interventions related to the resident's specific risk and and causes to try to prevent the resident from falling. The staff will implement the fall prevention plan to reduce the risk of falls. Review of the undated policy titled Safe Lifting and Movements of Residents revealed manual lifting of residents should be eliminated when feasible. Staff responsible for direct resident care will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 10 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 trained in the use of manual (gait/transfer belts, lateral boards) d mechanical lifting devices. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 11 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record reviews, and review of online Centers for Disease and Control (CDC) guidance, the facility failed to ensure the use of appropriate Personal Protective Equipment (PPE) and hand hygiene when providing care to residents in isolation precautions for active infection with Clostridium Difficile (C-Diff). This had the potential to affect all residents residing in the facility except two residents (#13 and #399) who had an active infection with C-Diff. The facility census was 48. Residents Affected - Many Findings include: Review for Resident #13's medical record revealed an admission date of 05/19/22 and had diagnosis including enterocolitis due to C-Diff infection. Review of the physicians order for Resident #13, dated 05/21/22, revealed an order for Vancomycin 125 milligram (mg) capsule, administer one capsule four times a day for 10 days for enterocolitis due to C-Diff. Record review for Resident #399 revealed this resident was admitted to the facility on [DATE] and had diagnoses including enterocolitis due to C-Diff infection. Review of the physician order for Resident #399, dated 05/27/22, revealed an order for contact precautions for C-Diff infection. Observation on 06/02/22 from 7:15 A.M. through 7:30 A.M., revealed Certified Nursing Assistant (CNA) #15 was observed to remove a breakfast meal tray from the cart and enter the room of Resident #13 without donning a gown or gloves. CNA #15 assisted Resident #13 to reposition in the bed and then exited the room without washing hands with soap and water, only hand sanitizer. CNA #15 then removed another breakfast meal tray from the cart and entered the room of Resident #399. CNA #15 assisted in setting up the breakfast meal tray for Resident #399 and exited the room without performing hand hygiene using soap and water, only hand sanitizer. CNA #15 then removed another breakfast meal tray from the cart and entered the room of Resident #400 to deliver and set up the resident's meal tray. Once finished, CNA #15 exited the room of Resident #400 and performed hand hygiene using hand sanitizer. CNA #15 then entered the communal kitchen, where several residents were observed eating their breakfast meal, and requested additional items from kitchen staff. Interview with CNA #15 on 06/02/22 at 7:30 A.M., revealed the employee had forgotten to wear a gown and gloves when assisting Resident #13 to reposition in the bed. CNA #15 verified only hand sanitizer was used to perform hand hygiene after exiting the rooms of Resident #13 and Resident #399, who were both on contact isolation for infection with C-Diff. Interview with Licensed Practical Nurse (LPN) #14 on 06/02/22 at 9:30 A.M. verified staff were to wear a gown when providing care for residents with C-Diff infection and were to perform hand hygiene by washing hands with soap and water after. Review of the online CDC guidance (https://www.cdc.gov/cdiff/clinicians/faq.html), titled FAQs for Clinicians about C. diff, last reviewed on 07/20/21, revealed Wear gloves and a gown when treating patients with C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff and hand washing might not be sufficient alone to eliminate all C. diff spores. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 12 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 the facility's vaccination matrix, review of staff vaccination records, staff interview, review of Centers for Medicare & Medicaid Services (CMS) memorandum, and review of the facility's policy, the facility failed to ensure 100 percent of their staff were fully vaccinated against COVID-19 or had been granted a medical or religious exemption. The vaccination rate for the facility was calculated at 94.2%. The facility census was 48. Residents Affected - Few Findings include: Review of the undated facility staff COVID-19 vaccination matrix revealed the facility had a total of 70 employees. There were 66 employees fully vaccinated for COVID-19 or were granted a medical or religious exemption and four employees partially vaccinated for COVID-19, indicating a staff vaccination rate of 94.2%. Review of the COVID-19 vaccination record for Activities Aide #2 revealed the employee had received the first dose of the Pfizer COVID-19 vaccine on 11/24/21. There was no documentation of the second dose of the vaccine being administered. Review of the COVID-19 vaccination record for Certified Nurse Aide (CNA) #50 revealed the employee had received the first dose of the Pfizer COVID-19 vaccine on 02/17/22. There was no documentation of the second dose of the vaccine being administered. Review of the COVID-19 vaccination record for CNA #54 revealed the employee had received the first dose of the Moderna COVID-19 vaccine on 11/26/21. There was no documentation of the second dose of the vaccine being administered. Review of the COVID-19 vaccination record for CNA #36 revealed the employee had received the first dose of the Pfizer COVID-19 vaccine on 11/24/21. There was no documentation of the second dose of the vaccine being administered. Interview with the Administrator on 06/02/22 at 11:44 A.M. verified the staff COVID-19 vaccination matrix was accurate. The Administrator verified all documentation of COVID-19 vaccinations and granted religious and medical exemptions were contained in the book provided and were accurate to her knowledge. The Administrator verified Activities Aide #2, CNA #50, CNA #54 and CNA #36 were not fully vaccinated and did not have a religious or medical exemption. The Administrator also verified there have no been no COVID-19 resident cases in the last four weeks. Review of the 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). Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 30 days after issuance of this memorandum, less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. Review of the policy titled Mandatory COVID-19 Vaccine Policy and Procedure, not dated, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 13 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 the facility required every staff member to be either vaccinated or have received approval for either a religious or medical exemption or a temporarily delayed vaccination. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 14 of 15 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 365221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Greenfield 850 Nellie Street Greenfield, OH 45123 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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, staff interviews, and review of the facility's policy, the facility failed to ensure a resident's call light was properly functioning. This affected one (Resident #19) of 16 residents reviewed in the initial pool sample. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, anxiety disorder, parapleural psychosis, and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had severe cognitive impairment. Resident #19 was assessed to required one-person extensive assistance with toileting and bathing. Observation on 05/31/22 at 11:12 A.M. revealed Resident #19's call light was lying on the floor underneath the bed. Resident #19's call light was not properly functioning. Interview on 05/31/22 at 11:15 A.M. with Occupational Therapist Assistant #64 verified Resident #19's call light was not properly functioning. Subsequent observation on 06/01/22 at 9:49 A.M. revealed Resident #19's call light was still not properly functioning. Interview on 06/01/22 at 11:42 A.M. with Licensed Practical Nurse (LPN) Supervisor #14 stated Resident #19 was able use his call light but does not normally do so. LPN Supervisor #14 was was not aware Resident #19's call light was not functioning. Observation and interview on 06/01/22 at 11:43 A.M. of LPN Supervisor #14 verified Resident #19's call light was not functioning properly. Review of the facility's policy titled, Answering the Call Light, revealed the purpose of this procedure was to ensure timely responses to the resident's requests and needs. Staff was to ensure the call light was plugged in and functioning at all times. Some residents may not be able to use their call light. Be sure to check those residents frequently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365221 If continuation sheet Page 15 of 15