Health inspection·September 26, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm (sponsor) of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 2 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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, observation, staff interviews, review of facility self-reported incidents (SRIs), and review of a facility policy, the facility failed to implement their abuse policy for injuries of unknown origin. This affected two (Resident #17 and #30) of six residents reviewed for abuse prohibition. The facility census was 70. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed an admission date of 02/02/15. Medical diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease, cerebrovascular disease, major depressive disorder, chronic peripheral venous insufficiency, chronic kidney disease, glaucoma, and diabetes mellitus. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. She was at risk for pressure ulcers. She had no unhealed pressure ulcers. She had no moisture associated skin damage. She required extensive assistance with one staff member for transfers, dressing, toilet use, and personal hygiene. She required supervision with one staff for walking in room, locomotion, and bed mobility. She was occasionally incontinent of urine, and always continent of bowel. She had no rejection of care. Review of the resident's nursing notes revealed an entry dated 07/10/19 at 4:21 P.M. The entry indicated edema of the resident's labia was noted which was purple in color. The resident stated there was discomfort. The physician was notified and Diflucan (antifungal medicine) was ordered. The evaluation was, will monitor and have the nurse practitioner look at her tomorrow during rounds. Review of the physician's orders revealed an order dated 07/10/19 to monitor swelling and/or discoloration to labia every shift until resolved. Review of the resident's shower/skin sheets revealed no perineal, buttock, or thigh impairments on 07/03/19. On 07/10/19, the shower/skin sheet indicated reddened area in groin/perineal area with no further description noted. Review of the resident's nurse practitioner/physician notes revealed she was not seen by the nurse practitioner until 07/12/19 at 1:57 P.M. The nurse practitioner documented the resident was seen for nursing concerns regarding swollen and dark colored labia. Resident denied pain or discomfort in vaginal or rectal area, vaginal drainage, dysuria, abdominal pain, rectal pain, problems with bowel or bladder. She was uncooperative during visit and did not allow staff to lay her down flat for examination. She did stand up with support from walker to allow visualization of vaginal area. Noticed significantly red and excoriated groin area, as well as labia. No discharge or odor noted. She did have some bruising noted to bilateral labia majora, which could be a deep tissue injury as the resident spends the majority of her time in her wheelchair and does not reposition herself throughout the day. Educated resident on repositioning herself while in wheelchair and increasing mobility as she might develop pressure ulcer in this area. Nystatin powder ordered for candidiasis of bilateral groins. Will encourage staff to keep area clean and dry with warm water and soap. Will get cushion for wheelchair from therapy to help alleviate pressure. She was at high risk of developing pressure ulcer because of her non-compliance and inability to cooperative or reposition herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 3 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's wound nurse practitioner noted dated 08/01/19 revealed she was seen for initial evaluation and management of wounds to her buttocks, thigh, and perineal region. Wound base was a diffuse area of maroon or purplish discoloration of intact skin, unable to be measured. No drainage, peri-labia region with edema. No pain. Diagnosis was unstageable pressure ulcer/injury of bilateral gluteus, thigh and perineal area secondary to deep tissue injury. Apply zinc barrier cream twice daily and as needed. Review of the facility SRIs revealed no SRI had been reported to the Ohio Department of Health since 06/20/19. Interview with the Administrator on 09/25/19 at 3:50 P.M. verified the facility did not follow their policy when they did not complete a SRI or thoroughly investigate Resident #30's injury of unknown injury discovered on 07/10/19 Observation of the resident's perineal area on 09/26/19 at 9:58 A.M. with Licensed Practical Nurse (LPN) #241 revealed the resident would only allow care while standing making it very difficult to visualize the area. Large, dark purple area noted to bottom, thighs bilaterally and labia. Bilateral labia appeared edematous and dark purple in color. The resident denied pain. Allowed the area to be cleansed and zinc applied. LPN #241 asked her if she knew what happened and she stated she did not know. No open areas were noted. Unable to obtain measurements due to resident was uncooperative. Interview with Wound Nurse Practitioner #300 on 09/26/19 at 12:39 P.M. revealed she saw Resident #30 for the first time on 08/01/19. She stated she felt the perineal and buttock skin discoloration and edema was a result of pressure and classified it as a deep tissue injury. She stated she did not suspect any type of abuse. 2. Review of the medical record for Resident #17 revealed an admission date on 06/07/19. Diagnoses included unspecified dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #17 had moderate cognition deficits and required one staff extensive assistance with bed mobility, toileting and personal hygiene. Further review of the medical record revealed an event note dated 08/08/19 at 9:45 A.M. documented a dark discoloration with edema, possible fluid filled, was noted to the left upper extremity. Resident denied pain to the area. The area measured 10.2 centimeters (cm), by 7.3 cm. The resident stated her husband had tried to pull her up in the bed and caused the discoloration. Discoloration appeared to have been caused by a blood pressure cuff. Review of the physician note dated 08/08/19 at 12:55 P.M. revealed Resident #17 was seen for bruising noted to the left upper extremity above the antecubital fossa. This was first noted by Resident #17 a couple days ago. Resident #17 complained of tenderness to the area and gave possibility of result of being transferred by staff. According to staff Resident #17's husband reported having stated he had been trying to pull her up in the bed and accidentally caused the bruise. A skin note dated 08/09/19 at 10:23 A.M. revealed an interdisciplinary team reviewed the discoloration and edema to the left upper extremity and it appeared to have been caused by the blood pressure cuff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 4 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Review of the facility SRIs revealed no report had been filed regarding this incident. Level of Harm - Minimal harm or potential for actual harm Interview on 09/25/19 at 3:50 P.M. with the Administrator verified the facility did not complete a SRI, thoroughly investigate, or follow their abuse policy when this injury of unknown origin was discovered. Residents Affected - Few Interview on 09/26/19 at 9:45 A.M. with Resident #17 revealed she was unaware of how the bruise occurred. She thought it could have been from her husband pulling her up in bed. Resident #17 denied having been abused. Review of an undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with the policy. An injury was classified as an injury of unknown source when both the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health (ODH) immediately, but not later than two hours after the allegation is made. All other allegations shall be reported to ODH as soon as possible but no later than 24 house from the time the incident/allegation was made known to the staff member. Once the Administrator and Ohio Department of Health are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days, unless special circumstances exist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 5 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of facility self-reported incidents (SRIs), and review of a facility policy, the facility failed to report injuries of unknown origin to the Ohio Department of Health. This affected two (Resident #17 and #30) of six residents reviewed for abuse prohibition. The facility census was 70. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 02/02/15. Medical diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease, cerebrovascular disease, major depressive disorder, chronic peripheral venous insufficiency, chronic kidney disease, glaucoma, and diabetes mellitus. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. She was at risk for pressure ulcers. She had no unhealed pressure ulcers. She had no moisture associated skin damage. She required extensive assistance with one staff member for transfers, dressing, toilet use, and personal hygiene. She required supervision with one staff for walking in room, locomotion, and bed mobility. She was occasionally incontinent of urine, and always continent of bowel. She had no rejection of care. Review of the resident's nursing notes revealed an entry dated 07/10/19 at 4:21 P.M. The entry indicated edema of the resident's labia was noted which was purple in color. The resident stated there was discomfort. The physician was notified and Diflucan (antifungal medicine) was ordered. The evaluation was, will monitor and have the nurse practitioner look at her tomorrow during rounds. Review of the physician's orders revealed an order dated 07/10/19 to monitor swelling and/or discoloration to labia every shift until resolved. Review of the resident's shower/skin sheets revealed no perineal, buttock, or thigh impairments on 07/03/19. On 07/10/19, the shower/skin sheet indicated reddened area in groin/perineal area with no further description noted. Review of the resident's nurse practitioner/physician notes revealed she was not seen by the nurse practitioner until 07/12/19 at 1:57 P.M. The nurse practitioner documented the resident was seen for nursing concerns regarding swollen and dark colored labia. Resident denied pain or discomfort in vaginal or rectal area, vaginal drainage, dysuria, abdominal pain, rectal pain, problems with bowel or bladder. She was uncooperative during visit and did not allow staff to lay her down flat for examination. She did stand up with support from walker to allow visualization of vaginal area. Noticed significantly red and excoriated groin area, as well as labia. No discharge or odor noted. She did have some bruising noted to bilateral labia majora, which could be a deep tissue injury as the resident spends the majority of her time in her wheelchair and does not reposition herself throughout the day. Educated resident on repositioning herself while in wheelchair and increasing mobility as she might develop pressure ulcer in this area. Nystatin powder ordered for candidiasis of bilateral groins. Will encourage staff to keep area clean and dry with warm water and soap. Will get cushion for wheelchair from therapy to help alleviate pressure. She was at high risk of developing pressure ulcer because of her non-compliance and inability to cooperative or reposition herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 6 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's wound nurse practitioner noted dated 08/01/19 revealed she was seen for initial evaluation and management of wounds to her buttocks, thigh, and perineal region. Wound base was a diffuse area of maroon or purplish discoloration of intact skin, unable to be measured. No drainage, peri-labia region with edema. No pain. Diagnosis was unstageable pressure ulcer/injury of bilateral gluteus, thigh and perineal area secondary to deep tissue injury. Apply zinc barrier cream twice daily and as needed. Review of the facility SRIs revealed no SRI had been reported to the Ohio Department of Health since 06/20/19. Interview with the Administrator on 09/25/19 at 3:50 P.M. verified the facility did not follow their policy when they did not complete a SRI or thoroughly investigate Resident #30's injury of unknown injury discovered on 07/10/19 Observation of the resident's perineal area on 09/26/19 at 9:58 A.M. with Licensed Practical Nurse (LPN) #241 revealed the resident would only allow care while standing making it very difficult to visualize the area. Large, dark purple area noted to bottom, thighs bilaterally and labia. Bilateral labia appeared edematous and dark purple in color. The resident denied pain. Allowed the area to be cleansed and zinc applied. LPN #241 asked her if she knew what happened and she stated she did not know. No open areas were noted. Unable to obtain measurements due to resident was uncooperative. Interview with Wound Nurse Practitioner #300 on 09/26/19 at 12:39 P.M. revealed she saw Resident #30 for the first time on 08/01/19. She stated she felt the perineal and buttock skin discoloration and edema was a result of pressure and classified it as a deep tissue injury. She stated she did not suspect any type of abuse. 2. Review of the medical record for Resident #17 revealed an admission date on 06/07/19. Diagnoses included unspecified dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #17 had moderate cognition deficits and required one staff extensive assistance with bed mobility, toileting and personal hygiene. Further review of the medical record revealed an event note dated 08/08/19 at 9:45 A.M. documented a dark discoloration with edema, possible fluid filled, was noted to the left upper extremity. Resident denied pain to the area. The area measured 10.2 centimeters (cm), by 7.3 cm. The resident stated her husband had tried to pull her up in the bed and caused the discoloration. Discoloration appeared to have been caused by a blood pressure cuff. Review of the physician note dated 08/08/19 at 12:55 P.M. revealed Resident #17 was seen for bruising noted to the left upper extremity above the antecubital fossa. This was first noted by Resident #17 a couple days ago. Resident #17 complained of tenderness to the area and gave possibility of result of being transferred by staff. According to staff Resident #17's husband reported having stated he had been trying to pull her up in the bed and accidentally caused the bruise. A skin note dated 08/09/19 at 10:23 A.M. revealed an interdisciplinary team reviewed the discoloration and edema to the left upper extremity and it appeared to have been caused by the blood pressure cuff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 7 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Review of the facility SRIs revealed no report had been filed regarding this incident. Level of Harm - Minimal harm or potential for actual harm Interview on 09/25/19 at 3:50 P.M. with the Administrator verified the facility did not complete a SRI, thoroughly investigate, or follow their abuse policy when this injury of unknown origin was discovered. Residents Affected - Few Interview on 09/26/19 at 9:45 A.M. with Resident #17 revealed she was unaware of how the bruise occurred. She thought it could have been from her husband pulling her up in bed. Resident #17 denied having been abused. Review of an undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with the policy. An injury was classified as an injury of unknown source when both the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health (ODH) immediately, but not later than two hours after the allegation is made. All other allegations shall be reported to ODH as soon as possible but no later than 24 house from the time the incident/allegation was made known to the staff member. Once the Administrator and Ohio Department of Health are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days, unless special circumstances exist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 8 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. 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, staff interviews, review of facility self-reported incidents (SRIs), and review of a facility policy, the facility failed to complete a thorough investigation of injuries of unknown origin. This affected two (Resident #17 and #30) of six residents reviewed for abuse prohibition. The facility census was 70. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed an admission date of 02/02/15. Medical diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease, cerebrovascular disease, major depressive disorder, chronic peripheral venous insufficiency, chronic kidney disease, glaucoma, and diabetes mellitus. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. She was at risk for pressure ulcers. She had no unhealed pressure ulcers. She had no moisture associated skin damage. She required extensive assistance with one staff member for transfers, dressing, toilet use, and personal hygiene. She required supervision with one staff for walking in room, locomotion, and bed mobility. She was occasionally incontinent of urine, and always continent of bowel. She had no rejection of care. Review of the resident's nursing notes revealed an entry dated 07/10/19 at 4:21 P.M. The entry indicated edema of the resident's labia was noted which was purple in color. The resident stated there was discomfort. The physician was notified and Diflucan (antifungal medicine) was ordered. The evaluation was, will monitor and have the nurse practitioner look at her tomorrow during rounds. Review of the physician's orders revealed an order dated 07/10/19 to monitor swelling and/or discoloration to labia every shift until resolved. Review of the resident's shower/skin sheets revealed no perineal, buttock, or thigh impairments on 07/03/19. On 07/10/19, the shower/skin sheet indicated reddened area in groin/perineal area with no further description noted. Review of the resident's nurse practitioner/physician notes revealed she was not seen by the nurse practitioner until 07/12/19 at 1:57 P.M. The nurse practitioner documented the resident was seen for nursing concerns regarding swollen and dark colored labia. Resident denied pain or discomfort in vaginal or rectal area, vaginal drainage, dysuria, abdominal pain, rectal pain, problems with bowel or bladder. She was uncooperative during visit and did not allow staff to lay her down flat for examination. She did stand up with support from walker to allow visualization of vaginal area. Noticed significantly red and excoriated groin area, as well as labia. No discharge or odor noted. She did have some bruising noted to bilateral labia majora, which could be a deep tissue injury as the resident spends the majority of her time in her wheelchair and does not reposition herself throughout the day. Educated resident on repositioning herself while in wheelchair and increasing mobility as she might develop pressure ulcer in this area. Nystatin powder ordered for candidiasis of bilateral groins. Will encourage staff to keep area clean and dry with warm water and soap. Will get cushion for wheelchair from therapy to help alleviate pressure. She was at high risk of developing pressure ulcer because of her non-compliance and inability to cooperative or reposition herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 9 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's wound nurse practitioner noted dated 08/01/19 revealed she was seen for initial evaluation and management of wounds to her buttocks, thigh, and perineal region. Wound base was a diffuse area of maroon or purplish discoloration of intact skin, unable to be measured. No drainage, peri-labia region with edema. No pain. Diagnosis was unstageable pressure ulcer/injury of bilateral gluteus, thigh and perineal area secondary to deep tissue injury. Apply zinc barrier cream twice daily and as needed. Review of the facility SRIs revealed no SRI had been reported to the Ohio Department of Health since 06/20/19. Interview with the Administrator on 09/25/19 at 3:50 P.M. verified the facility did not follow their policy when they did not complete a SRI or thoroughly investigate Resident #30's injury of unknown injury discovered on 07/10/19 Observation of the resident's perineal area on 09/26/19 at 9:58 A.M. with Licensed Practical Nurse (LPN) #241 revealed the resident would only allow care while standing making it very difficult to visualize the area. Large, dark purple area noted to bottom, thighs bilaterally and labia. Bilateral labia appeared edematous and dark purple in color. The resident denied pain. Allowed the area to be cleansed and zinc applied. LPN #241 asked her if she knew what happened and she stated she did not know. No open areas were noted. Unable to obtain measurements due to resident was uncooperative. Interview with Wound Nurse Practitioner #300 on 09/26/19 at 12:39 P.M. revealed she saw Resident #30 for the first time on 08/01/19. She stated she felt the perineal and buttock skin discoloration and edema was a result of pressure and classified it as a deep tissue injury. She stated she did not suspect any type of abuse. 2. Review of the medical record for Resident #17 revealed an admission date on 06/07/19. Diagnoses included unspecified dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #17 had moderate cognition deficits and required one staff extensive assistance with bed mobility, toileting and personal hygiene. Further review of the medical record revealed an event note dated 08/08/19 at 9:45 A.M. documented a dark discoloration with edema, possible fluid filled, was noted to the left upper extremity. Resident denied pain to the area. The area measured 10.2 centimeters (cm), by 7.3 cm. The resident stated her husband had tried to pull her up in the bed and caused the discoloration. Discoloration appeared to have been caused by a blood pressure cuff. Review of the physician note dated 08/08/19 at 12:55 P.M. revealed Resident #17 was seen for bruising noted to the left upper extremity above the antecubital fossa. This was first noted by Resident #17 a couple days ago. Resident #17 complained of tenderness to the area and gave possibility of result of being transferred by staff. According to staff Resident #17's husband reported having stated he had been trying to pull her up in the bed and accidentally caused the bruise. A skin note dated 08/09/19 at 10:23 A.M. revealed an interdisciplinary team reviewed the discoloration and edema to the left upper extremity and it appeared to have been caused by the blood pressure cuff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 10 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Review of the facility SRIs revealed no report had been filed regarding this incident. Level of Harm - Minimal harm or potential for actual harm Interview on 09/25/19 at 3:50 P.M. with the Administrator verified the facility did not complete a SRI, thoroughly investigate, or follow their abuse policy when this injury of unknown origin was discovered. Residents Affected - Few Interview on 09/26/19 at 9:45 A.M. with Resident #17 revealed she was unaware of how the bruise occurred. She thought it could have been from her husband pulling her up in bed. Resident #17 denied having been abused. Review of an undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with the policy. An injury was classified as an injury of unknown source when both the following conditions are met. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health (ODH) immediately, but not later than two hours after the allegation is made. All other allegations shall be reported to ODH as soon as possible but no later than 24 house from the time the incident/allegation was made known to the staff member. Once the Administrator and Ohio Department of Health are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days, unless special circumstances exist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 11 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure physician orders were added to the resident's record in a timely manner. This affected one resident (Resident #26) out of six residents reviewed for physician orders. The current census is 70. Residents Affected - Few Findings include: Review of Resident #26's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarctions, cognitive deficit, dysphagia, insomnia, and Parkinson's disease. Review of the Minimum Data Set (MDS),comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of the communication documentation revealed on 09/22/19 the resident's physician was notified the resident was complaining of a non-productive cough. Per the communication document the physician responded on 09/23/19 at 2:59 P.M. with an order for Mucinex (an expectorant) 600 milligram (mg) orally three times a day. Review of Resident #26's physician orders dated 09/25/19 revealed the resident was ordered to have Mucinex 600 mg orally every eight hours. Review of Resident #26's Medication Administration Record, (MAR) dated 09/2019 revealed the Mucinex was ordered on 09/25/19 and there had been no doses administered to the resident. Interview on 09/25/19 at 9:50 A.M. with Licensed Practical Nurse, (LPN) #248 revealed a physician order for and as needed (PRN) Mucinex 600 mg orally came for Resident #26 and the order was not added to the resident's medical chart until 09/25/19. Per LPN #248 faxes from the physician were often being 'lost' and orders for resident's medications were being delayed as a result of the communication records not being added to the resident's chart on the same day the order was received. Interview on 09/25/19 at 10:09 A.M. with Resident #26 revealed the resident had been having a 'bad hacking cough' for a few days. Per Resident #26 the nurse informed him the physician had ordered something for the cough. He was told he would be receiving medications for his cough but had not received any medication and still had been coughing. Interview on 09/25/19 at 1:40 P.M. with the Director of Nursing (DON) verified the notification to the physician for the residents coughing was faxed on 09/22/19 and the physician responded on 09/23/19 with an order for the Mucinex. The DON verified the only order in Resident #26's record for Mucinex was dated 09/25/19 and no doses had been given to the resident. The DON verified the order was delayed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 12 of 13 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 365448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home Inc 1096 North Ohio Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to ensure posted daily nurse staffing information contained the actual hours worked. This had the potential to affect all 70 residents. Residents Affected - Many Findings include: Observation of the daily nurse staffing posting dated 09/23/19 through 09/26/19 revealed the postings did not contain the actual hours worked by the nurses or State Tested Nursing Assistant (STNA) staff. Interview with the Director of Nursing on 09/26/19 at 12:30 P.M. verified the daily nurse staffing postings did not contain the actual hours worked by the nurses or STNA staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365448 If continuation sheet Page 13 of 13