Inspection·August 1, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of policy, the facility failed to ensure fingernails were trimmed and maintained in a sanitary manner. This affected one (#13) of three reviewed for activities of daily living. The census was 62. Residents Affected - Few Findings include: Review of Resident #13's medical record revealed an admission date of 10/05/18. Diagnoses included chronic obstructive pulmonary disease, obsessive-compulsive disorder, need for assistance with personal care, hyperlipidemia, adult failure to thrive, dementia with behavioral disturbance, and diabetes mellitus type II. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderately impaired cognition, was assessed to require extensive one person physical assistance with personal hygiene, and assessed with no rejection of care during the assessment time period. Observation on 07/25/22 at 3:50 P.M., revealed Resident #13 sitting in the reclining chair in his bedroom. Observation of Resident #13's hands revealed several of his finger nails were long and extended over the ends of the fingertips on both hands. There was also a build up of a blackish-brown colored substance under at least four of Resident #13's fingernails. An interview was attempted with Resident #13 on 07/25/22 at 3:51 P.M., however, Resident #13 hung his head and put his hands up by his face when questions were asked and did not appropriately respond to the questions. Observation on 07/26/22 at 11:07 A.M., at 2:36 P.M., on 07/27/22 at 11:32 A.M., and at 3:22 P.M. revealed Resident #13's finger nail remained long and the blackish-brown substance remained under the finger nails. Review of nurses aide behavior monitoring dated between 07/15/22 and 07/26/22 revealed Resident #13 displayed no rejection of care during that time frame. Interview on 07/27/22 at 11:54 A.M., with Registered Nurse (RN) #462 stated Resident #13 picked his nose a lot and it caused him to bleed, and the blood would sometimes get on his hands an face. RN #462 stated the staff have wash Resident #13's hands and face when they see he caused his nose to bleed. RN #462 stated the staff have to help Resident #13 wash his hands and trim his finger nails because Resident #13 would not do it on his own. RN #13 stated Resident #13 always allowed her to clean his hands and trim his fingernails and stated the last time she trimmed Resident #13's finger nails was approximately one month ago. Observation on 07/27/22 at 3:35 P.M., revealed Resident #13 was laying in bed. Further observation with RN #462 confirmed Resident #13's finger nails were long and had a blackish-brown substance under many of them. Interview on 07/27/22 at 3:35 P.M., with RN #462 stated it did not appear Resident #13's fingernails had been trimmed since the last time she trimmed them approximately one month ago. RN #462 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 2 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0677 she would clean out the substance under Resident #13's finger nails and trim them. Level of Harm - Minimal harm or potential for actual harm Review of an undated policy titled, Activities of Daily Living (ADLs), revealed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 3 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and policy review, the facility failed to implement pressure relief interventions to prevent the development of pressure ulcers. This affected one (#20) of two residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers acquired in the facility in a census of 62. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed an admission date of 05/31/21, with diagnoses including hypertensive heart disease with failure, dementia with behavioral disturbances, congestive heart failure , Type II diabetes, anxiety disorder, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/29/22 revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS) indicating the resident has severe cognitive deficits. She displayed verbal and physical behaviors toward others on 1- 3 days of the assessment period. She requires extensive assistance of two staff members for bed mobility and transfers. She is not ambulatory. She is frequently incontinent of bowel and bladder. She is at risk for the development of pressure ulcers with no current pressure ulcers. Review of the plan of care updated 04/29/22, revealed the resident has potential for pressure ulcer development related to immobility, incontinence, and cognitive deficits. She requires extensive assist for bed mobility. The goal is for the resident to have intact skin, free of redness, blisters or discoloration through next review date. The interventions include pressure relieving/reducing devices on the bed and chair and turning and reposition to ensure the resident's comfort. Review of the physician orders revealed an order initiated on 06/23/21 for a pressure redistribution mattress to be placed on the resident's bed. Review of Wound Evaluation and Management Summary dated 04/04/22 stated resident presents with a wound to her right buttocks. She has a shear wound to the right buttocks measuring 0.2 centimeters (cm) by 0.2 cm by 0.1 cm depth. Review of Wound Evaluation and Management Summary , dated 04/11/22 stated the wound to her right buttocks had healed . The evaluation stated there were preventative recommendations put in place . Further review of the evaluation revealed no preventative recommendations mentioned on evaluation. Review of Wound Evaluation and Management Summary dated 06/20/22 stated the resident has a wound to her right buttocks with multiple open areas measuring 3 cm. by 4.1 cm. by 0.1 cm. Further review of the medical record revealed the wound was measured weekly with increase in the measurements. On 07/18/22, the treatment to the right buttock was changed to calogen powder daily to enhance healing with dietary interventions. Observation on 07/26/22 at 12:20 P.M. and 2:00 P.M., revealed Resident #20 was in bed on her back with her eyes closed. The low air loss mattress was set on the stasis setting. Interview on 07/26/22 at 3:43 P.M., with Agency Registered Nurse (RN) #462 verified the low air loss mattress was set on the stasis mode. She stated she did not know what the mattress was to be set (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 4 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0686 on. She verified Resident #20 was lying on her back. Level of Harm - Minimal harm or potential for actual harm Interview on 07/26/22 at 4:30 P.M., with the Director of Nursing stated she ordered the low loss air mattress with defined perimeters to prevent falls from the bed not for pressure relief. Residents Affected - Few Interview on 07/27/22 at 9:30 A.M., with the Director of Nursing stated she had ordered the low air loss mattress with defined perimeter. She stated she ordered it initially for falls as the resident lays very close to the edge of the bed. However, she thought the resident could benefit from the pressure reduction due to current pressure ulcers and refusing to be turned. She stated she spoke to Wound Physician #500, this morning and she dictated a note approving the low air loss mattress and recommending the facility check with the mattress company for settings. The Director of Nursing stated she had called the company who supplied the bed for the appropriate settings. Review of the Progress Note dated 07/27/22 written by Wound Physician # 500 stated Resident #20 had pressure injuries and she had witnessed the resident's constant refusals for care and repositioning, The progress note stated Wound Physician #500 wanted the resident to be on a low air loss mattress to provide pressure off loading of current wounds and to prevent future pressure injuries. The recommendation was to have the low air lost mattress company set the bed for the resident's weight and needs. Observations on 07/27/22 at 10:00 A.M., 11:30 A.M., 12:20 P.M., and 2:00 P.M., revealed Resident #20 was in bed on her left side with a pillow wedged single thickness under her right side. The low air loss mattress was set on stasis. Observation on 07/27/22 at 3:55 P.M., revealed RN #408 provided wound care for Resident #20. The wounds ere measured by RN #408 and measured 6 cm. in length and 6 cm. in width with a depth of 0.1 on the interior portion of the right buttock. The resident's entire buttocks appeared to be purple in color. The resident cried out during the cleansing of the open areas and when the calogen powder was applied. Interview on 07/27/22 at 5:30 P.M., with Director of Nursing stated she had not heard back on the setting for the alternating air mattress. Interview on 07/27/22 at 5:40 P.M., with Cooperate Nurse #461 stated she had the setting for the mattress from the company and was just waiting for the physician to approve the order. Review of the undated policy Prevention of Pressure Ulcer revealed the resident should be assessed for skin breakdown risks and pressure relieving devices implemented based on the resident's risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 5 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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, observations, staff interviews, and policy review, the facility failed to implement fall prevention interventions for two residents (#47 and #48) of three residents reviewed for falls. The facility census was 62. Findings include: 1. Review of Resident #48's medical record revealed an admission date of 09/27/21, with diagnoses including Parkinson's Disease, dementia with behaviors, muscle wasting and aphasia. Review of significant change in status Minimum Data Set (MDS) assessment, dated 07/07/22, revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive deficits. He did not exhibit any behaviors and had no falls since the last assessment. Review of the plan of care updated 07/07/22 stated Resident #48 is at risk falls and fall related injuries. He has a history of having recurrent falls, but has not had any serious injury caused by these; has an unsteady gait; has standing balance impairments due to Parkinson's, tremors, polyneuropathy, and decreased safety awareness at times. Resident #48 is noncompliant with waiting for staff assistance and using his call light; makes frequent attempts to get up unassisted; and has been educated on fall precautions and serious adverse affects. Fall interventions include a fall mat to the right side of his bed, maintain bed in a low bed position maintain his bed against the wall to provide him sufficient, space within which to maneuver hid wheelchair,use light clip to secure the call light and make it easily accessible to his hand upon completion of his daily care needs, and non skid socks on when resident is in bed. Review of the nursing progress note dated 06/12/22 at 8:01 A.M., stated Resident #48 was found lying on his left side in bathroom doorway. The resident stated he was trying to get up from the toilet. He had regular socks on at the time. He had no pain at the time. Later he complained of right hip pain. Results of an x-ray revealed no fracture. Review of the Reportable Event/ Root Cause Analysis, dated 07/14/22 for the fall on 06/12/22 stated involving Resident #48, the fall was with negative outcome. The analysis stated the resident had regular socks on slipped and fell in the bathroom . Observation on 07/26/22 at 2:20 P.M., revealed Resident #48 was lying in his bed on his back with left side of his head leaning on the upper side rail. In low bed . A fall mat was folded up by the head of the right side of the bed. Left side of bed against the wall. Observation on 07/27/22 at 10:30 A.M., revealed the resident was up in a recliner in his room. The call light was wrapped around the upper side rail of the bed out of the resident's reach. Interview on 07/26/22 at 11:15 A.M., with Registered Nurse (RN) # 462 verified Resident #48 was capable of using his call light. Interview on 07/27/22 at 11:20 A.M., with State Tested Nursing Assistant (STNA) #451 verified Resident #48 was capable of using the call light. She verified the resident's call light was not within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 6 of 22 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 365447 B. Wing (X3) DATE SURVEY COMPLETED A. Building 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 reach of the resident. He was in the recliner and his call light was on his bed. Level of Harm - Minimal harm or potential for actual harm Interview on 07/27/22 at 2:00 P.M., with Resident #48 was observed in bed with his shoes off and regular socks on. He did not have nonskid socks on. The left side of his low bed was against the wall and there was no fall mat by the right side of his bed. Residents Affected - Few Interview on 07/27/22 at 4:00 P.M., with Resident #48 was observed in bed with his shoes off and regular socks on. He did not have non skid socks on. The left side of his low bed was against the wall and there was no fall mat by the right side of his bed. Observation on 07/27/22 at 5:15 P.M., with Resident #48 was observed in bed with his shoes off and regular socks on. He did not have non kid socks on. The left side of his low bed was against the wall and there was no fall mat by the right side of his bed. RN MDS Coordinator #408 verified the resident did not have a fall mat by his bed or nonskid socks on as per fall interventions listed in the plan of care. Review of the undated policy Falls Policy and Procedures stated based on assessment the Interdisciplinary Team will develop interventions based on the resident's risk factors and implement a fall plan of care. 2. Review of the medical record for Resident #47 revealed an admission date of 06/12/22. Diagnoses included Alzheimer's disease, hypertension, atrial fibrillation, cerebral infarction, and type II diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired, required extensive assistance with transfers, bed mobility, ambulation, dressing, and toilet use. Resident #47 was always continent of bladder and occasionally incontinent of bowel. Additionally, Resident #47 had one fall with injury. Review of the fall risk assessment dated [DATE] revealed Resident #47 was at risk for falls. Review of facility incident reports revealed Resident #47 had falls on 06/15/22, 06/27/22, 06/28/22, 07/01/22, and 07/07/22. Each of these incident reports indicated the fall occurred when Resident #47 was attempting to go to the bathroom unassisted or was found near the bathroom. Review of a facility incident report dated 06/21/22 revealed Resident #47 fell after using the bathroom, Resident #47 did not call for assistance, and the Resident sustained a fractured rib. Review of the plan of care, revised 07/14/22, revealed Resident #47 was at risk for falls and fall related injuries and made attempts to get up unassisted when she experienced bladder and bowel urgency. Interventions included bedside commode in room by bed to assist with unsafe transfers. Observations on 07/25/22 at 4:04 P.M., 07/26/22 at 10:02 A.M., and 07/26/22 at 2:19 P.M. revealed Resident #47 sitting on the side of her bed in her room during each observation. A bedside commode was not observed in the room. Interview on 07/26/22 at 3:00 P.M., with State Tested Nurse Aide (STNA) #447 confirmed Resident #47 required extensive one person assistance with transfers, ambulation, and toilet use. STNA #447 was unable to verbalize Resident #47's fall interventions, stating Resident #47 had never fallen when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 7 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 she was working with her so she did not know what her fall interventions were. STNA #447 verified Resident #47 did not have a bedside commode. Additionally, STNA #447 stated she would ask the nurse what fall interventions were in place if a resident fell. Interview on 07/28/22 at 8:46 A.M., with Licensed Practical Nurse (LPN) #458 verified a bedside commode was located in Resident #47's bathroom. LPN #458 was unaware of the care plan fall intervention for Resident #47 to have a bedside commode near her bed. LPN #458 confirmed most of Resident #47's falls were related to the Resident going to the bathroom unassisted. Interview on 07/28/22 at 9:44 A.M., with the Director of Nursing (DON) verified Resident #47 had a falls care plan intervention to have a bedside commode near the bed due to numerous falls related to the Resident going to the bathroom unassisted. The DON stated the intent was for the bedside commode to be available at all times, but especially at night. The DON confirmed the care plan did not indicate any specific time the bedside commode should be available. Review of the undated policy titled Falls Policy and Procedures, revealed for residents with one or more falls, applicable interventions will be implemented in accordance with the assessment and appropriate interventions will be documented on the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 8 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, the facility failed establish the medical necessity for the continued use of an indwelling catheter, maintain the catheter for privacy and to prevent potential infections. This affected one (#44) of one resident reviewed for the extended use of a indwelling catheter. The census was 62. Findings include: Review of Resident #44's medical record revealed an admission date of 06/08/, with diagnoses including: morbid obesity, chronic obstructive pulmonary disease, hypertension, sleep apnea, depression, and gout. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive deficits. He had no behaviors. The resident has a indwelling catheter in place and is frequently incontinent of bowel. Review of the MDS Care Area Assessment (CAA) dated 06/15/22 stated the urinary incontinence CAA was triggered secondary to use of an indwelling catheter. The risk factors of an indwelling catheter includes recurrent urinary tract infections. A plan of care will initiated to maintain he catheter per physician's orders and decrease the risk for recurrent urinary tract infections. Review of the plan of care dated 0/15/22 stated Resident# 44 has a catheter due to benign Prostrate Hypertrophy (BPH) and acute kidney failure. Interventions include positioning the catheter tubing below the level of the bladder and away from entrance of the room door. Interview on 07/25/22 at 2:40 P.M., with Resident #44 stated he came to the facility following a hospitalization for an infection. He stated the catheter was placed in the hospital and it was very painful at the time of placement. He stated it is still painful at times and he hopes it will come out soon Observation on 07/26/22 at 12:25 P.M., revealed Resident #44 revealed he was sitting up in bed with his lunch tray in front of him. The catheter bag was hanging from the bed frame facing the door. There catheter bag was half full of yellow urine. The catheter bag had no privacy bag . Observation on 07/27/22 at 9:45 A.M., revealed Resident #44 was in bed. He stated he had just returned from therapy. The catheter bag was on the lower bed frame facing the door to his room without a privacy bag in place. He stated he was going out to the physician office due to knee pain. Observation on 07/27/22 at 12:25 P.M. revealed Resident #44 returned from the physician visit with community transport. The catheter bag was tucked in seat of wheelchair beside the resident without a privacy bag in place. Interview on 07/27/22 at 1:00 P.M., with Resident #44 stated when he gets up in the wheelchair they always place his catheter bag in the seat of his wheelchair. He stated when his catheter bag is in the seat of the wheelchair it is painful. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 9 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/27/22 at 5:20 P.M., Registered Nurse (RN) MDS Coordinator #408 verified Resident #44 catheter bag was facing the entrance of his room with no privacy bag. She verified the residents plan of care stated the catheter bag was to be on the other side of the bed facing away from the room entrance. She verified the facility's policy was to cover all catheter bags with a privacy bag. Interview on 07/27/22 at 5:45 P.M., with RN MDS Coordinator #408 verified the resident did not have a diagnosis for the continued use of an indwelling catheter. She verified she had put in the plan of care the resident had benign prostate hypertrophy and acute renal failure which she stated was not an expectable diagnoses for continuation of the indwelling catheter. She stated on 07/01/22 the resident's primary physician visited him at the facility but did not address the indwelling catheter. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 10 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure blood glucose monitoring was completed as ordered. This affected one (#56) of five residents observed during medication administration. The facility identified 16 residents with physician orders for blood glucose monitoring. The census was 62. Residents Affected - Few Findings include: Review of Resident #56's medical record revealed an admission date of 03/11/20. Diagnoses included unspecified dementia with behavioral disturbances, diabetes mellitus type II, muscle weakness, chronic obstructive pulmonary disease, aphasia, and essential hypertension. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was assessed with moderately impaired cognitive skills for daily decision making. Review of a physician order dated 06/21/21 revealed Resident #56 was ordered Humalog insulin injected subcutaneously and to be administered via a sliding scale. The ordered sliding scale was as follows: for blood glucose levels between 151 milligrams per deciliter (mg/dL) and 200 mg/dL, give two units of insulin; between 201 mg/dL and 250 mg/dL, give four units of insulin; between 251 mg/dL and 300 mg/dL, give six units of insulin; between 301 mg/dL and 350 mg/dL, give eight units of insulin; and between 351 mg/dL and 400 mg/dL, give ten units of insulin. Resident #56 was ordered to have her blood glucose levels checked before meals and at bedtime to determine if sliding scale insulin was needed. Review of Resident #56's July 2022 medication administration record (MAR) revealed blood glucose checks were scheduled to be obtained at 6:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M. daily. Observation on 07/25/22 at 11:50 A.M., revealed the lunch meal trays arrived to the secured unit and staff began passing the meals to residents. All residents, including Resident #56, were observed eating in the common dining space on the unit while a nurse aide remained with the residents to assist and monitor. Resident #56 was observed eating her food and drink items independently and was free from any distress or change in condition. After all residents were finished with their meals the nurse aide cleared the meals trays and placed them back on the serving cart at 12:28 P.M. Observation on 07/25/22 at 12:37 P.M., revealed a nurse entered the secured unit and walked to the medication cart. Interview on 07/25/22 at 12:37 P.M., with Registered Nurse (RN) #462 verified she was the nurse assigned to the secured unit on 07/25/22 and stated this was the first she was able to make it back to the unit. RN #462 stated the wound physician needed her to make rounds so she was at least two hours behind on her medication administration and the secured unit was the last unit she needed to finish. RN #462 stated another nurse usually went with the wound physician on wound rounding days but that nurse was assisting the administrative team at that time. RN #462 confirmed Resident #56 was the only resident on the secured unit with orders for insulin and verified she did not check it before Resident #56's lunch meal on 07/25/22. Observation on 07/25/22 at 12:46 P.M., revealed RN #462 obtained Resident #56's blood glucose level (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 11 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0757 Level of Harm - Minimal harm or potential for actual harm and it was 135 mg/dL and did not require any insulin to be administered. Resident #56's remained free from distress and acute changes in condition. Review of the July 2022 MAR revealed Resident #56's blood glucose level on 07/25/22 at 4:00 P.M. was 133 mg/dL and did not require any insulin to be administered. Residents Affected - Few Interview on 07/28/22 at 2:11 P.M., with Corporate Nurse #461 stated the facility did not have a policy related to blood glucose monitoring and would follow the physician orders for obtaining resident blood glucose levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 12 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected five (#2, #12, #14, #56, and #59) of five residents observed during medication administration. A total of 15 medications errors were observed out of 28 medications administered which resulted in a medication error rate of 53.57 percent (%). The census was 62. Residents Affected - Some Findings include: 1. Review of Resident #56's medical record revealed an admission date of 03/11/20. Diagnoses included unspecified dementia with behavioral disturbances, muscle weakness, chronic obstructive pulmonary disease, diabetes mellitus type II, aphasia, and essential hypertension. Review of physician orders dated 06/21/21 revealed Resident #56 was ordered the nerve pain medication Gabapentin 100 milligrams (mg) by mouth three times daily, the acid reducer famotidine 20 mg by mouth twice daily, and the supplement ferrous sulfate 325 mg by mouth three times daily. Review of a physician order dated 11/03/21 revealed Resident #56 was ordered the blood pressure medication metoprolol 25 mg by mouth twice daily. Review of a physician order dated 07/18/22 revealed Resident #56 was ordered the antipsychotic medication Seroquel 25 mg by mouth twice daily. Review of the July 2022 medication administration record (MAR) revealed Resident #56's famotidine, metoprolol, and Seroquel were all scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Resident #56's Gabapentin was scheduled to be given at 9:00 A.M., 2:00 A.M., and 8:00 P.M. daily; and Resident #56's ferrous sulfate was scheduled to be given at 8:00 A.M., 2:00 P.M., and 8:00 P.M. Observation on 07/25/22 at 12:46 P.M., revealed Resident #56 was administered her Gabapentin, famotadine, metoprolol, Seroquel, and ferrous sulfate by Registered Nurse (RN) #462. 2. Review of Resident #14's medical record revealed an admission date of 09/20/18. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, major depression, hyperlipiemidia, anxiety disorder, and dementia with behavioral disturbance. Review of physician orders dated 06/21/21 revealed Resident #14 was ordered the supplement potassium chloride 10 milliequivalents (mEq) by mouth twice daily and the antipsychotic Risperdal one mg tablet with a 0.5 mg tablet to equal 1.5 mg total dose by mouth twice daily. Review of the July 2022 MAR revealed Resident #14's potassium chloride and Risperdal were scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 12:49 P.M., revealed Resident #14 was administered her potassium chloride and Risperdal by RN #462. 3. Review of Resident #12's medical record revealed an admission date of 09/06/21. Diagnoses included Alzheimer's disease, dysphagia, muscle weakness, dementia with behavioral disturbances, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 13 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0759 schizoaffective disorder, major depression, and essential hypertension. Level of Harm - Minimal harm or potential for actual harm Review of a physician order dated 06/21/21 revealed Resident #12 was ordered the seizure medication Keppra 500 mg by mouth twice daily. Residents Affected - Some Review of the July 2022 MAR revealed Resident #12's Keppra was scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 12:53 P.M., revealed Resident #14 was administered her Keppra by RN #462. 4. Review of Resident #59's medical record revealed an admission date of 01/15/22. Diagnoses included unspecified dementia without behavioral disturbances, secondary Parkinsonism, muscle weakness, schizoaffective disorder, and cardiac murmur. Review of a physician order dated 01/15/22 revealed Resident #59 was ordered the medication for Parkinson's disease Simemet 25-100 mg by mouth three times daily. Review of a physician order dated 07/21/22 revealed Resident #59 was ordered the nasal decongestant Flonase 50 micrograms per inhalation with orders to inhale two sprays in each nostril daily. Review of the July 2022 MAR revealed Resident #59's Sinement was scheduled to be administered at 8:00 A.M., 2:00 P.M., and 8:00 P.M. daily, and Flonase was scheduled to be administered between 7:00 A.M. and 11:00 A.M. daily. Interview on 07/25/22 at 12:56 P.M., with RN #462 stated Resident #59's Flonase was not available in the medication cart and Resident #59 would not receive the medication on 07/25/22 because it needed to be ordered. Observation on 07/25/22 at 12:58 P.M., revealed Resident #59 was administered her Sinemet by RN #462. 5. Review of Resident #2's medical record revealed an admission date of 08/15/17. Diagnoses included unspecified dementia with behavioral disturbances, anxiety, mixed receptive-expressive language disorders, and cognitive communication deficit. Review of a physician order dated 06/22/21 revealed Resident #2 was ordered the pain medication Tylenol 650 mg by mouth three times daily. Review of a physician order dated 04/26/22 revealed Resident #2 was ordered the anti-anxiety medication Buspar five mg by mouth twice daily. Review of a physician order dated 06/30/22 revealed Resident #2 was ordered the mood stabilizer Depakote 125 micrograms two tablets by mouth twice daily. Review of the July 2022 MAR revealed Resident #2's Tylenol was scheduled to be administered at 8:00 A.M., 2:00 P.M., and 8:00 P.M. and Resident #2's Buspar and Depakote were scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 14 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 07/25/22 at 1:05 P.M., revealed Resident #2 was administered her Tylenol, Buspar, and Depakote by RN #462. Interview on 07/25/22 at 12:37 P.M., with RN #462 verified she was the nurse assigned to the secured unit on 07/25/22 and stated this was the first she was able to make it back to the unit. RN #462 stated the wound physician needed her to make rounds so she was at least two hours behind on her medication administration and the secured unit was the last unit she needed to finish. RN #462 stated another nurse usually went with the wound physician on wound rounding days but that nurse was assisting the administrative team at that time. RN #462 verified all of Resident #2, #12, #14, #56, and #59's medications were administered late. Review of the policy titled, Medication Administration, dated 2020, revealed nurses should administer medications as ordered in accordance with manufacture specifications. The medication should be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 15 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medication administration was completed without significant medication errors. This affected five (#2, #12, #14, #56, and #59) of five residents observed during medication administration. The census was 62. Residents Affected - Some Findings include: 1. Review of Resident #56's medical record revealed an admission date of 03/11/20. Diagnoses included unspecified dementia with behavioral disturbances, muscle weakness, chronic obstructive pulmonary disease, diabetes mellitus type II, aphasia, and essential hypertension. Review of physician orders dated 06/21/21 revealed Resident #56 was ordered the nerve pain medication Gabapentin 100 milligrams (mg) by mouth three times daily. Review of a physician order dated 07/18/22 revealed Resident #56 was ordered the antipsychotic medication Seroquel 25 mg by mouth twice daily. Review of the July 2022 medication administration record (MAR) revealed Resident #56's Seroquel was scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Resident #56's Gabapentin was scheduled to be given at 9:00 A.M., 2:00 A.M., and 8:00 P.M. daily. Observation on 07/25/22 at 12:46 P.M., revealed Resident #56 was administered her Gabapentin and Seroquel by Registered Nurse (RN) #462. 2. Review of Resident #14's medical record revealed an admission date of 09/20/18. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, major depression, hyperlipiemidia, anxiety disorder, and dementia with behavioral disturbance. Review of physician orders dated 06/21/21 revealed Resident #14 was ordered the antipsychotic Risperdal one mg tablet with a 0.5 mg tablet to equal 1.5 mg total dose by mouth twice daily and the diuretic Lasix 20 mg by mouth daily. Review of the July 2022 MAR revealed Resident #14's Risperdal was scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily, and Lasix scheduled to be administered between 7:00 A.M. and 11:00 A.M. daily. Observation on 07/25/22 at 12:49 P.M., revealed Resident #14 was administered her Lasix and Risperdal by RN #462. 3. Review of Resident #12's medical record revealed an admission date of 09/06/21. Diagnoses included Alzheimer's disease, dysphagia, muscle weakness, dementia with behavioral disturbances, schizoaffective disorder, major depression, and essential hypertension. Review of a physician order dated 06/21/21 revealed Resident #12 was ordered the seizure medication Keppra 500 mg by mouth twice daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 16 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the July 2022 MAR revealed Resident #12's Keppra was scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 12:53 P.M., revealed Resident #14 was administered her Keppra by RN #462. 4. Review of Resident #59's medical record revealed an admission date of 01/15/22. Diagnoses included unspecified dementia without behavioral disturbances, secondary Parkinsonism, muscle weakness, schizoaffective disorder, and cardiac murmur. Review of a physician order dated 01/15/22 revealed Resident #59 was ordered the medication for Parkinson's disease Simemet 25-100 mg by mouth three times daily. Review of the July 2022 MAR revealed Resident #59's Sinement was scheduled to be administered at 8:00 A.M., 2:00 P.M., and 8:00 P.M. daily. Observation on 07/25/22 at 12:58 P.M., revealed Resident #59 was administered her Sinemet by RN #462. 5. Review of Resident #2's medical record revealed an admission date of 08/15/17. Diagnoses included unspecified dementia with behavioral disturbances, anxiety, mixed receptive-expressive language disorders, and cognitive communication deficit. Review of a physician order dated 04/26/22 revealed Resident #2 was ordered the anti-anxiety medication Buspar five mg by mouth twice daily. Review of a physician order dated 06/30/22 revealed Resident #2 was ordered the mood stabilizer Depakote 125 micrograms two tablets by mouth twice daily. Review of the July 2022 MAR revealed Resident #2's Buspar and Depakote were scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 1:05 P.M., revealed Resident #2 was administered her Buspar and Depakote by RN #462. Interview on 07/25/22 at 12:37 P.M., with RN #462 verified she was the nurse assigned to the secured unit on 07/25/22 and stated this was the first she was able to make it back to the unit. RN #462 stated the wound physician needed her to make rounds so she was at least two hours behind on her medication administration and the secured unit was the last unit she needed to finish. RN #462 stated another nurse usually went with the wound physician on wound rounding days but that nurse was assisting the administrative team at that time. RN #462 verified all of Resident #2, #12, #14, #56, and #59's medications were administered late. Review of policy the policy titled, Medication Administration, dated 2020, revealed nurses should administer medications as ordered in accordance with manufacture specifications. The medication should be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 17 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure appropriate sanitation when serving meals and failed to keep pureed meat at a safe holding temperature to potentially prevent foodborne illness. This had the potential to affect 62 of 62 residents. The facility census was 62. Findings include: 1. Observation on 07/25/22 at 11:12 A.M., of Assistant Dietary Supervisor (ADS) #467 checking the holding temperature of pureed fish revealed the temperature of the fish on the holding steam table was 120 degrees Fahrenheit. Interview of ADS #467, at the time of the observation, verified the pureed fish was 120 degrees. ADS #467 stated she set the temperature on the holding table at 175 degrees Fahrenheit but she was unsure of what the hot food holding temperature should be to prevent foodborne illness. ADS #467 stated the pureed fish had set outside of the steam table a little longer while she was getting other food ready. ADS #467 was unsure how long the pureed fish had been left sitting before placing on the holding table. 2. Observation on 07/25/22 at 11:15 A.M., of lunch tray line service revealed ADS #467 don gloves before plating resident's lunches. With her left, gloved hand, ADS #467 picked up a plate and placed it on the serving counter. ADS #467 used the same left, gloved hand to guide peas onto the plate. Without changing her gloves, ADS #467 picked up pieces of fish and placed one piece on each of five plates. Wearing the same gloves, ADS #467 continued to touch serving utensils and use her left hand to guide peas and fried potatoes onto each of the five plates, making contact with the peas and potatoes with her left, gloved hand as she plated each plate. ADS #467 placed each plate onto a cart and pushed the cart toward the exit from the kitchen, grabbed an empty cart and moved it closer to the serving area. Interview of ADS #467, at the time of the observation, verified she touched food and non-food items with the same gloves hands, stating she used to her hands to make sure the foods did not touch each other when she plated the food. ADS #467, without changing her gloves, returned to the holding table and began plating four meals, again using her hands to guide food onto the plates. 3. Observation on 07/25/22 at 11:33 A.M., of lunch tray service on the 300 Hall revealed State Tested Nurse Aide (STNA) #417 enter Resident #4's room with a lunch tray. STNA #417 assisted Resident #4 with meal set up, including uncovering food items and cutting up fish. STNA #417 exited Resident #4's room, without performing hand hygiene, removed a tray from the cart, and entered Resident #42's room and delivered the lunch tray. STNA #417 exited Resident #42's room, without performing hand hygiene, and delivered a lunch tray to Resident #24. STNA #417 did not perform hand hygiene, removed a tray from the cart and delivered the lunch meal to Resident #31, removing the plate cover and plastic wrap from Resident #31's dessert. STNA #417 removed a tray from the cart and entered Resident #47's room. STNA #417 assisted Resident #47 with meal set up, including removing coverings from food items and cutting up the fish. STNA #417 exited the room, without performing hand hygiene, and pushed the meal cart to the end of the hall. STNA #417 delivered a meal tray to Resident #34, picked up the last meal tray from the cart, and entered Resident #1's room. STNA #417 assisted Resident #1 with meal set up, including uncovering food items and cutting up fish. Upon exiting Resident #1's room, STNA #417 performed hand hygiene. Interview on 07/25/22 at 11:40 A.M., of STNA #417 verified she did not perform hand hygiene while delivering meal trays and providing set up assistance, stating she must have missed it a couple of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 18 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 times. Level of Harm - Minimal harm or potential for actual harm Review of the undated policy titled Dietary, revealed the dietary manager will ensure all staff practice proper hand washing techniques and proper glove use. In addition, dietary staff will ensure that all foods are held at appropriate temperatures, greater than 135 degrees for holding hot foods. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 19 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 2. Observation of incontinent care on 07/26/22 at 3:45 P.M., revealed State Tested Nursing Assistant (STNA) #455 removed a wet incontinent brief from Resident #20. STNA #455 cleasened the anterior and posterior peri areas with wipes. She disposed of the wipes and the wet brief in the trash can close to the bed. She applied a protective cream to the resident's buttocks. She placed a clean incontinent brief under the resident. She removed her gloves and disposed of them in the trash can by the bed with the wipes and the wet brief. She removed the liner from the trash can and tied the top of the liner placing it on the floor. The resident had an unopened container of jello on the over bed table which the resident stated she wanted. STNA #455 opened the jello set it down on the over bed table and stated she would feed Resident #20 the jello as soon as she got another liner for the trash can. She went into the bathroom obtained a liner for the trash can and placed it in the trash can . She obtained a spoon from the over bed table and began feeding the resident the jello. After she fed the resident the jello see washed her hands in the resident's bathroom. The entire time STNA #455 was in the room providing care and feeding the resident jello her surgical mask did not cover her nose. The top of the mask rested on her upper lip. Residents Affected - Many Interview with STNA #455 on 07/26/22 at 3:55 P.M., she verified she did not wash her hands following incontinent care and before feeding Resident #20 jello. She stated she didn't think about it. Interview with Licensed Practical Nurse (LPN) #435 on 07/26/22 at 4:00 P.M., verified STNA #455 was wearing a surgical mask just covering her mouth and not covering her nose. She stated she is constantly reminding staff to wear their masks properly covering their mouth and nose. Interview with Registered Nurse (RN) #457 on 07/26/22 at 4:05 P.M., verified STNA #455 was wearing a surgical mask just covering her mouth and not covering her nose. She stated she is constantly reminding staff to wear their masks properly covering their mouth and nose and at times just to wear a mask. Based on observation, staff interview, infection control log review, tuberculosis risk assessment review, review of personnel files, and review of a facility policies, the facility failed to monitor for trends and patterns of infections in the facility based on facility policy, failed to sanitize hands and wear appropriate personal protective equipment (PPE) during resident care interactions, and failed to ensure the facility followed their tuberculosis risk assessment in monitoring staff for potential tuberculosis infections. This deficiency had potential to affect 62 of 62 residents residing in the facility. The census was 62. Findings include: 1. Review of infection control logs from May, June, and July 2022 revealed each resident with an infection was placed on a spreadsheet and the following information documented: the unit the resident resided on the date of the infection, the resident's name, room number, signs and symptoms including the date, the site of the infection, if the infection was a urinary tract infection did the resident have a urinary catheter, culture or organism if applicable, antibiotic use with stop and start date, if placed on isolation, if symptoms were present on admission, if the infection was acquired in the facility, and if the antibiotic usage met McGeer criteria (nationally-recognized infection surveillance criteria). Further review of the infection control log spreadsheets revealed each entry was documented in alphabetical order by the resident's last name with no method to identify trends of infections in the facility by date, infection type, or location. There was no documentation of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 20 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many tracking or trending of infections in the space designated for such data at the end of each infection control log spreadsheet. There were no identifiable trends of infections identified on the May, June, and July 2022 infection control logs. Interview on 07/27/22 at 12:55 P.M., with Director of Nursing (DON) #1 verified she was in charge of the infection control program, but that duty had been shared many times over the last year. DON #1 stated the facility used to use a map of the facility with color coding of infections to identify potential trends of infections in the facility but had not done that since at least the beginning of 2022. DON #1 verified there was no analysis of infections completed at any time during the month and no tracking or trending data completed as well. DON #1 stated there were no trends or patterns of infections in the facility for at least all of 2022. Observation between 07/25/22 and 07/28/22 between 8:00 A.M. and 4:00 P.M., revealed no residents in the facility on ordered infection control precautions. Review of an undated policy titled, Infection Control Protocol and Tracking, revealed the infection control nurse designee will complete the monthly infection summary to monitor trends. When the resident acquires an infection, the infection control nurse/designee will update the surveillance map by reviewing the location the location the resident resides and type and location of infection. If there is a pattern, this will be discussed in the weekly quality assurance programs meeting 3. Review of State Tested Nurse Aide (STNA) #431's personnel record revealed a hire date of 09/09/20. The record contained evidence of a two-step mantoux tuberculin skin test (TST) completed upon hire. The record was silent for annual TST testing. Review of STNA #447's personnel record revealed a hire date of 09/02/20. The record contained evidence of a two-step TST completed upon hire. The record was silent for annual TST. Review of STNA #455's personnel record revealed a hire date of 09/03/20. The record contained evidence of a two-step TST completed upon hire. The record was silent for annual TST. Interview on 07/28/22 at 2:29 P.M., with the Administrator verified there was no evidence STNAs #431, #447, or #455 were tested, or screened, annually for tuberculosis (TB), with the last TST completed upon hire. Review of the facility's TB risk assessment and control plan, dated 03/28/22, revealed healthcare workers would be tested for TB upon hire and annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 21 of 22 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Potential for minimal harm Based on infection control log review, staff interview, and review of a facility policy, the facility failed to thoroughly review antibiotic usage prescribed by the physician and monitor for outcomes of antibiotic usage. This had potential to affect 62 of 62 residents residing in the facility. The census was 62. Residents Affected - Many Findings include: Review of infection control logs June and July 2022 revealed each resident with an infection was placed on a spreadsheet and the following information documented: the unit the resident resided on the date of the infection, the resident's name, room number, signs and symptoms including the date, the site of the infection, if the infection was a urinary tract infection did the resident have a urinary catheter, culture or organism if applicable, antibiotic use with stop and start date, if placed on isolation, if symptoms were present on admission, if the infection was acquired in the facility, and if the antibiotic usage met McGeer criteria (nationally-recognized infection surveillance criteria). Further review of the June and July 2022 infection control log spreadsheets revealed there was no tracking of antibiotic usage outcomes and the facility did not consistently review McGeer criteria to establish if the antibiotic medication was appropriate. In total, four of 42 antibiotics used in the facility during these months were reviewed to determine if McGeer criteria was met. Review of infection control logs from May, June, and July 2022 revealed no identifiable infection patterns or trends in the facility. Interview on 07/27/22 at 12:55 P.M., with Director of Nursing (DON) #1 verified she was in charge of the infection control program, but that duty had been shared many times over the last year. DON #1 stated did not have a method to track antibiotic use outcomes and she was not reviewing McGeer criteria to determine appropriateness of antibiotic usage. DON #1 stated she was not aware what McGeer criteria was and was simply guessing, based on her own knowledge, if antibiotics were appropriate for each resident prescribed them and documenting a decision on the infection control log spreadsheets under the McGeer criteria column. DON #1 stated there were no trends or patterns of infections in the facility for at least all of 2022. Observation between 07/25/22 and 07/28/22 between 8:00 A.M. and 4:00 P.M. revealed no residents in the facility on ordered infection control precautions. Review of an undated facility policy titled, Antibiotic Stewardship Program, revealed the facility will track and monitor antibiotic prescribing and utilization. Tracking will include outcomes of antibiotic use i.e. C-difficile infection, rate of drug resistant organisms, and rate of adverse drug events due to antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365447 If continuation sheet Page 22 of 22