Health inspection·March 14, 2019

F 0684 Level of Harm - Minimal harm or potential for actual harm observations or circulation assessments had been documented in the medical record. Corporate RN#1 stated ongoing assessments including circulation checks of the casted extremity should have been recorded. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 2 of 8 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 365663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Genoa Retirement Village 300 Cherry St Genoa, OH 43430 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, pharmacy recommendations, interview and facility policy review, the facility physician failed to timely address the gradual dose reduction (GDR) recommendations for one (Resident #12) of five residents reviewed for unnecessary medications. The facility census 67. Findings included: Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE]. Diagnoses included weakness, bipolar disorder, anxiety disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, essential tremor, hypothyroidism, seizures, depression and unspecified dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was receiving antipsychotic, antianxiety and antidepressant medications. Review of the Plan of Care revised 01/23/19 revealed Resident #12 was at risk for adverse consequences related to receiving antipsychotic medications. Interventions included to attempt GDR in two separate quarters (with at least one month between the attempts) during the first year the resident received an antipsychotic medication, unless clinically contraindicated. Attempt to give the lowest dose possible. Review of the current physician orders revealed Resident #12 had Ativan 0.5 milligrams (mg) twice daily, mirtazapine 15 mg daily at bedtime, Sertraline 100 mg daily, Trazodone 50 mg daily at bedtime and Zyprexa 7.5 mg daily at bedtime. These medications were all originally ordered on 04/02/18, then reordered on 04/23/18 and reordered again on 11/21/18 with no changes to the medication doses or administration times. Review of the facility pharmacist GDR recommendation dated 04/04/18 revealed When a resident is admitted on an antipsychotic a gradual dose reduction must be attempted within the first two weeks of admission (with an exception if treating Schizophrenia, Huntington's, or Tourette's). Resident #12 was admitted on Zyprexa 7.5 mg daily at bedtime. Do you feel a gradual dose reduction is appropriate? If not, please provide an explanatory note. Thank you. The physician was notified on 04/04/18. The physician never responded to the pharmacy recommendation. The physician did not agree or disagree, did not provided a justification for Resident #12 to remain on the Zyprexa. The pharmacy recommendation was noted as closed on 04/24/18. Review of the MDS dated [DATE] revealed Resident #12 was discharged to the hospital. The MDS dated [DATE] revealed Resident #12 returned to the facility on [DATE]. Review of the facility pharmacist GDR recommendation dated 04/24/18 revealed Resident #12 was re-admitted on Zyprexa 7.5 mg daily at bedtime on 04/23/18, do you feel a gradual dose reduction is appropriate? If not, please provide an explanatory note. In the evaluation notes section of the recommendation the pharmacist noted the Physician has not responded to recommendations after contact on 04/24/18, 05/01/18 and again on 05/04/18. There was no response from the physician. The physician did not agree or disagree. The recommendation was documented as closed on 05/09/18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 3 of 8 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 365663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Genoa Retirement Village 300 Cherry St Genoa, OH 43430 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the scanned pharmacy recommendation document dated 04/24/18 revealed the recommend was address by the physician and declined. The physician did not date the note. The date of the physician's response was unknown. Review of the facility pharmacist recommendation dated 06/05/18 revealed a request to please clarify diagnosis for the use of Trazodone (insomnia or depression), Remeron (appetite, depression, or insomnia) and Carbamazepine. The response to the recommendation was a diagnoses of depression and Bipolar are on resident chart for use with these medications. The recommendation was closed on 08/20/18 by a facility Registered Nurse (RN). The was no documentation by the physician regarding the recommendation. Review of the facility pharmacist recommendation dated 07/05/18 revealed a note to the nurses indicating a physician recommendation was made on 04/04/18, 04/24/18, and 06/05/18. The 06/05/18 recommendation was still open and needed to be addressed. The other recommendations made on 04/04/18 and 04/24/18 were closed with the statement that physician has not responded after three attempts. This is not acceptable. If recommendations are not responded to, they must be followed up with a phone call to physician to be compliant with state regulations. The only response was this was noted. The recommendation was closed 07/16/18. Review of the facility pharmacist GDR recommendation dated 08/06/18 revealed when a psychopharmacological medication was being used to manage behavior, stabilize mood, or treat a psychiatric disorder, gradual dose reductions should be attempted twice within the first year (in two separate quarters with at least one month between attempts), and then yearly thereafter. This resident was due for an attempted GDR. If the resident was deemed unsuitable for GDR, the following conditions must be met in order for GDR to be clinically contraindicated: the continued use was in accordance with current standards of practice, AND the physician had documented clinical rationale or the resident's target symptoms returned or worsened after the most recent tapering attempt within the facility, and the physician had documented clinical rationale. This resident's medication that was due for evaluation was Zyprexa 7.5 mg daily at bedtime, Remeron 15 mg daily at bedtime, Trazodone 50 mg daily at bedtime, Zoloft 100 mg daily, and Ativan 0.5 mg twice daily. The physician was notified on 08/07/18 with a note stating, Awaiting a response. The physician did not agree or disagree. The recommendation was closed on 08/07/18. Review of the facility pharmacist GDR recommendation dated 09/05/18 the exact same recommendation from 08/06/18 was submitted to the facility again for a GDR of Zyprexa, Remeron, Trazodone, Zoloft and Ativan. This GDR was declined by the physician with justification on 09/06/18. Interview with Corporate RN #1 on 03/13/19 at 4:23 P.M., verified the physician never responded to the pharmacy recommendation dated 04/04/18. She verified the recommendation was issued again by the pharmacist on 04/24/18. RN #1 verified the pharmacist added additional information to the 04/24/18 recommendation which stated the Physician has not responded to recommendations after contact on 04/24/18, 05/01/18 and again on 05/04/18. The recommendation was documented as closed on 05/09/18. RN #1 verified the recommendation was addressed by the physician, however, the physician did not date the response. RN #1 verified it was unknown when the physician actually completed her response. RN #1 verified the recommendation dated 04/24/18 was not addressed timely by the physician. RN #1 verified the recommendation dated 06/05/18 was never addressed by the physician and it was not closed until 08/20/19. RN #1 verified on 07/05/18 the pharmacy notified the facility regarding the 06/05/18 recommendation was still open and needed to be addressed and the physician had not responded after three attempts to the recommendations made on 04/4/18 and 04/24/18. RN #1 verified on 08/06/18 the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 4 of 8 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 365663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Genoa Retirement Village 300 Cherry St Genoa, OH 43430 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pharmacist submitted another GDR recommendation to which the physician never responded until after it was resubmitted on 09/05/18. Review of the facility policy titled Guidelines for Physician Services revised 05/11/16 revealed the resident's attending physician shall participate in the resident's assessment and care planning, monitor changes in the resident's medical status and provide consultation or treatment as required by resident condition, regulations and or when consulted/called by the facility. The physician is responsible to ensure that the resident receives quality care and medical treatments. Event ID: Facility ID: 365663 If continuation sheet Page 5 of 8 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 365663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Genoa Retirement Village 300 Cherry St Genoa, OH 43430 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #8's medical record re admitted to the facility on [DATE] following hospitalization with the diagnoses including, acute kidney failure, iron deficiency anemia, unspecified dementia without behavioral disturbance, colostomy, heart failure, essential hypertension, nephrotic syndrome with unspecified morphologic changes, chronic kidney disease stage 4, acute tubular necrosis, hypothyroidism, nonrheumatic aortic stenosis, diverticulitis of large intestine without perforation or abscess without bleeding, osteoarthritis, arteriosclerotic heart disease of native coronary artery without angina pectoris, thrombocytopenia, muscle weakness, diarrhea, and enterocolitis due to Clostridium difficile(C-Diff). Residents Affected - Few According to the most current minimum data set assessment (MDS) dated [DATE] identified the resident with moderate cognitive impairment, and dependent on staff for the completion of activities of daily living. On 02/28/19, the physician ordered the resident to be on contact precautions until C-Diff was resolved. Observation on 03/11/19 at 7:40 P.M. isolation cabinets containing isolation gowns, gloves and mask were located outside Resident #8's entry door. On 03/12/19 at 2:33 P.M. no isolation equipment was located outside the residents room. On 03/12/19, a laboratory test was received indicating a positive C-Difficile result. Interview with Licensed Practical Nurse (LPN) #300 on 02/12/19 at 2:35 P.M. verified the isolation equipment had been removed. LPN#300 stated no negative C-Dff stool specimen had been received for Resident #8 and was unaware why the equipment had been removed. Additional observation on 03/13/19 at 07:11 A.M., with Registered Nurse(RN) #200 revealed Resident #8 was still in C-Diff isolation and a isolation cart(cabinet) was maintained outside room. RN#200 looked in the direction of the residents room and verified no cart(cabinet) was present. On 03/13/19 at 8:03 A.M., State Tested Nurse Aide ((STNA) #400 was observed providing Resident #8 with a bed bath which included incontinence care of liquid stool. STNA #400 had gloves donned. However, no further isolation equipment was applied. At 8:13 A.M., STNA#400 requested Physical Therapy Assistant (PTA) #500 to assist in pulling the resident up in bed. PTA #500 was observed to handle the resident and associated linens without donning isolation equipment. At the conclusion of the observations, interview with STNA#500 stated the resident was no longer on isolation and isolation equipment was no longer required during the provision of care. On 03/13/19 at 9:10 A.M., interview with Corporate RN #1 verified no negative C-Diff test result had been obtained and isolation equipment had been removed from Resident #8's room. Corporate RN #1 indicated isolations remained in place. Review of facility guidelines for management of residents with Clostridium Difficile revised 05/11/16 revealed staff are to wear gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the residents environment. Donning a gown and gloves upon room entry and discarding before exiting the patient room was done to contain pathogens. 3. Resident #30 admitted to the facility on [DATE] with the diagnoses including, sepsis, chronic systolic congestive heart failure, type 2 diabetes mellitus, dementia, benign prostatic hyperplasia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 6 of 8 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 365663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Genoa Retirement Village 300 Cherry St Genoa, OH 43430 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 - Few severe protein-calorie malnutrition, hypertension, arteriosclerosis of coronary artery bypass graft, cardiac pacemaker, rhabdomyolysis, history of urinary tract infection, and acute myocardial infarction. According to the most current minimum data set assessment (MDS) dated [DATE] identified the resident as cognitively impaired, dependent on staff for the completion of activities of daily living, and requires the use of an indwelling urinary catheter. On 03/02/19 a physician order for a Indwelling Urinary Catheter for the treatment of Obstructive Uropathy was implemented. Surveyor observation on 03/12/19 at 2:17 P.M., 03/13/19 at 6:25 A.M., 7:56 A.M., 9:00 A.M., 1:21 P.M. Resident #30 was in bed with the excess urinary catheter tubing resting on the floor. On 03/13/19 at 1:50 P.M., interview with Licensed Practical Nurse (LPN) #300 during observation verified resident with the catheter tubing on floor. LPN#300 proceeded to contain the tubing off the floor and verified catheter tubing was to be off the floor to prevent urinary tract infection. Additional observation on 03/14/19 at 7:43 A.M. noted Resident #30 in bed with the catheter tubing resting on the floor. Review of urinary catheter care policy revised 05/11/16 ensure the catheter tubing and drainage bag are kept off the floor. Based on medical record review, observation, staff interview and review of a facility policy, the facility failed to ensure appropriate infection control techniques and procedures were followed while provided incontinence and urinary catheter care. The facility further failed to provide proper storage of urinary catheters and promote the isolation of infectious diseases. This affected three residents (#34, #30, and #8) of 17 residents reviewed for infection control practices during the annual survey. The facility census was 67. Findings include: 1. Medical record review revealed Resident #34 admitted to the facility on [DATE]. Diagnoses included a stage four sacral pressure ulcer, severe protein calorie malnutrition, urine retention, obstructive uropathy, and dementia. Review of the quarterly Minimum Data Set assessment, dated 01/09/19, revealed the resident had impaired cognition. Further review of the medical record revealed the resident was diagnosed with a urinary tract infection on 10/01/18, 10/23/18, 12/22/18, 01/15/19, and 02/19/19. Review of Resident #34's physician orders revealed the resident had a Foley catheter (urinary catheter) and an order dated 10/06/17 revealed the facility was to provide Foley catheter care every shift. Observation on 03/13/19 at 11:25 A.M., revealed State Tested Nursing Assistant (STNA) #401 and STNA #402 provided incontinence care and urinary catheter care for Resident #34. Both STNA's washed their hands and put on clean gloves prior to providing care. STNA #401 provided peri-care for Resident #34 while STNA #402 assisted to position the resident. After providing per-care, STNA #401 proceeded to provide catheter care. STNA #401 was observed holding onto the tubing of Resident #34's catheter with her left gloved hand while cleansing the tube with her right gloved hand. After providing the care, STNA #401 entered the bathroom to obtain a graduate (container to collect and measure urine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 7 of 8 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 365663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Genoa Retirement Village 300 Cherry St Genoa, OH 43430 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 - Few drained from the catheter collection bag), placed a paper towel barrier onto the floor under the urinary catheter collection bag and placed the graduate onto the paper towel . She then opened the drain spout and drained the urine into the graduate. [NAME] #401 then used alcohol wipes to clean the drainage bag spout. STNA #401 emptied the graduate, used wipes to clean the graduate after use, removed her gloves, and washed her hands. At no time during the provided care was STNA #401 observed washing her hands or changing her gloves. Interview on 03/13/19 at 11:39 A.M., STNA #401 verified she did not remove her gloves and wash her hands after providing incontinence and and/or prior to providing urinary catheter care. STNA #401 revealed it was the facility's policy to remove her gloves and wash her hands after providing incontinence care and before providing urinary catheter care. STNA #401 stated she should have removed her gloves and washed her hands prior to providing catheter care. Review of a facility policy titled, Urinary Catheter Care, dated 05/11/2016, revealed to perform urinary catheter care staff were to wash and dry their hands thoroughly and put on gloves. Staff were to then wash the resident's genitalia and perineum thoroughly, place the soiled linens into a designated container, remove their gloves and discard them into the designated container. Further review revealed staff were to again wash their hands thoroughly and put on clean gloves and then proceed with providing the resident with catheter care. After the procedure staff were to again wash their hands thoroughly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 8 of 8