Inspection·April 22, 2021

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, observation, resident and staff interview, the facility failed to ensure interventions to prevent incontinence and potential associated urinary tract infections (UTIs) were implemented timely. This affected one Resident (#8) of 16 reviewed for incontinence care. The facility census was 39. Findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and chronic kidney disease. Review of Resident #8's physician orders dated 07/09/20 revealed an order for a diuretic medication, Furosemide 20 milligrams (mg) twice daily with the first dose between 4:30 A.M. to 6:00 A.M., and the second daily dose between 11:00 A.M. and 1:00 P.M. No documentation was noted in the record to address the increased frequency of urination experienced as a result of the diuretic medication administration. Review of Resident #8's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, and dependent on staff for the completion of activities of daily living (ADLs) including bed mobility, transfer, the use of a wheelchair for mobility, and frequently incontinent of bladder. Further review recorded the daily administration of an anti-depressant medication and diuretic medication. Review of Resident #8's plan of care dated 03/01/19, and revised on 03/24/21 revealed a plan of care was developed to address the resident experiencing episodes of incontinence related to immobility, medication use, and needs assistance with toileting and transfers. Interventions included encourage fluids unless contraindicated, observe for signs and symptoms of UTI, notify physician as needed, observe skin and report any signs of breakdown as needed, offer and assist with toileting as needed and/or per request, provide incontinence care as needed, provide incontinence products as needed. There was no evidence in the medical record identified or implemented specific to toileting or incontinence monitoring schedules for Resident #8. Review of Resident #8's laboratory urinalysis (U/A) and culture sensitivity (C&S) testing completed on 03/08/21 revealed the resident tested positive for UTI. The physician was contacted and an antibiotic Bactrim DS was ordered twice daily for seven days. On 04/15/21 a U/A and C&S revealed the resident tested positive for UTI. The physician was contacted and the antibiotic Bactrim DS was ordered twice daily for seven days. There was no evidence of any additional interventions put in place to address the prevention of further UTIs or to address incontinence. Review of the bladder activity report between 04/16/21 and 04/21/21 revealed Resident #8 was noted to be incontinent 15 of 22 times. The report also listed the resident as frequently incontinent of bladder. Observation and interview on 04/19/21 at 1:16 P.M. with Resident #8 revealed the resident was concerned due to her frequent UTIs. The resident revealed she was dependent on staff for ADLs and slept (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 2 of 5 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 04/22/2021 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 0690 in her recliner. Level of Harm - Minimal harm or potential for actual harm Observation and interview with Resident #8 on 04/21/21 at 10:20 A.M. revealed the resident was incontinent of urine frequently and staff had to place her on the toilet to clean her. She revealed there was no specific schedule for toileting and has had to wait at times, causing incontinence. Residents Affected - Few On 04/21/21 at 10:24 A.M. interview with State Tested Nurse Aide (STNA) #100 verified Resident #8 was incontinent of urine and confirmed no specific schedule is set for the resident to be assisted with toileting, and the resident would call out if care was needed. The STNA revealed they would place the resident on the toilet to conduct incontinence care. At 11:58 A.M. interview with STNA #100 revealed Resident #8 was just asked if she needed to use the restroom and she stated no, the STNA verified the resident was incontinent. The STNA revealed they would ask again around 1:00 P.M. or 2:00 P.M. Additional interview at 1:45 P.M. with the STNA revealed she had went in to ask the resident if she needed to use the bathroom and the resident said she was fine. The STNA verified she did not check for incontinence and last toileted the resident at 10:15 A.M. STNA #100 revealed her shift was complete at 2:00 P.M., and verified the resident was frequently incontinent and not on a toileting schedule or check/change schedule. On 04/22/21 at 2:30 P.M. interview with Corporate Nurse (CN) #1 and Assessment Nurse (AN) #2 verified the nurse aide care delivery data base indicates Resident #8 was to be checked every two hours. However, the two hour checks were not specific to Resident #8's continence/incontinence needs and verified no individualized interventions were established to address the residents incontinence or toileting needs for direct care staff to utilize. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 3 of 5 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 04/22/2021 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 Based on observation, staff interview, review of facility's guidelines, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Pandemic guidance, the facility failed to ensure healthcare personnel applied appropriate transmission based infection control precautions and personal protective equipment (PPE) to potentially prevent the spread of COVID-19. Additionally, the facility failed to ensure medications were administered to prevent cross contamination. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Residents Affected - Many Findings include: Observation on 04/20/21 at 12:45 P.M. revealed Physical Therapy Director(PTD) #1 exited Resident #141's room. PTD #1 removed an isolation gown, and disposable gloves, and walked into the corridor. PTD #1 was noted to keep a disposable surgical mask applied. Interview with PTD #1 at the time of the observation revealed Resident #141 was in quarantine for Covid-19 precautions due to being a new admission. PTD #1 revealed facility policy required disposable masks, goggles/face shield, gown, and gloves. The disposable surgical mask could be worn from room to room and did not need to be changed unless soiled. PTD #1 further revealed therapy staff provided care to residents through out the facility and wore the same mask in and out of those non-quarantine or isolation rooms also. On 04/20/21 at 1:15 P.M. interview with Registered Nurse (RN) #501 who was identified as the facility's Infection Control Preventionist, revealed she was assigned to the quarantine unit and also worked with non-quarantine residents. RN #501 identified four residents (#24, #141, #142, #143) residing on the hall who were currently in quarantine for Covid-19 precautions. RN #501 revealed the facility infection control policy allowed staff to wear a disposable surgical mask from room to room and not wear a N95 mask when providing care to quarantine residents. Review of facility Covid-19 guidelines for PPE revised 03/23/21, revealed staff working with quarantine residents are recommended to wear a N95 mask or loop mask. The mask should be removed and discarded at the end of the shift or if the mask becomes soiled, damaged or hard to breathe through. According to CDC Strategies for Optimizing the Supply of N95 FFRs updated October 19, 2020 follow a continuum using the surge capacity approach in the order of conventional (everyday practice), contingency (expected shortages), and crisis (known shortages) capacities. N95 FFRs are meant to be disposed after each use. CDC developed contingency and crisis strategies to help healthcare facilities conserve their supplies in the face of shortages. When the availability of N95 FFRs become limited due to an expected shortage, supplies first should be conserved using contingency strategies. Contingency Strategies include with extended use, N95 FFRs are worn for a prolonged period, for multiple patient contacts, before being removed and discarded (unlike conventional strategies in which an N95 FFR is used for one patient contact then discarded). This will slow the N95 FFR burn rate to help alleviate supply concerns. N95 FFRs are used beyond the manufacturer designated shelf-life for fit testing and training. After attempting the above contingency strategies and there is still a known shortage of N95 FFRs and available supplies cannot meet needs based on the current burn rate, crisis capacity strategies can be used. Crisis Capacity Strategies: Respirators (including N95 FFRs and other types of respirators) are used beyond the manufacturer-designated shelf life for health care delivery. Respirators are used that are similar to NIOSH-approved respirators but are not NIOSH approved and are approved according to standards used in other countries. The performance of some internationally approved respirators was evaluated by NIOSH and the results can be found on the CDC website. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 4 of 5 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 04/22/2021 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 - Many Respirators are used that have reached the manufacturer-designated shelf life but have not been evaluated by NIOSH. With limited reuse, an N95 FFRs is donned for one patient contact, then doffed and stored before being used for another patient contact for a limited number of donning's. The use of N95 FFRs and facemask's is prioritized by healthcare activity type. This guidance provides information on how to determine if, and when, a healthcare facility should be operating under N95 FFR crisis capacity situations during the COVID-19 pandemic and how to appropriately implement limited reuse of N95 FFRs, including their reuse after decontamination. How to determine if an N95 FFR crisis capacity strategy is needed because crisis capacity strategies are not compatible with US standards of care, crisis capacity strategies should only be implemented when there are known shortages of N95 FFRs and only after conventional and contingency strategies have been implemented. The ability to implement specific crisis capacity strategies will depend on the on-hand inventory. The flow chart provided on the CDC website can assist healthcare facility respiratory program managers in determining if their healthcare facility should operate under a crisis capacity situation. Use the PPE Burn Rate Calculator to help you plan and optimize the use of PPE. On 04/21/21 at 10:15 A.M. observation with Regional Registered Nurse (RRN) #1 noted a significant amount of N95 mask, gowns, gloves, face shields, and goggles in storage. RRN #1 stated the facility was not experiencing a shortage of N95 mask or PPE. 2. Observation of medication administration on 04/21/21 at 8:07 A.M. with RN #500 revealed the nurse was dispensing medication for Resident #27. The RN was observed pushing the tablet medication directly from the blister packet into her bare hand. After putting the medication into her hand, RN #500 placed the tablets in a medication cup. Interview with RN #500 at the time of the observation confirmed she failed to use infection control protocol for medication administration. Review of the facility policy titled Equipment and Supplies for Administering Medications, dated 11/2018, revealed to provide proper hand hygiene prior to handling tablets and examination gloves must be worn to prevent the touching of tablets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 5 of 5