Health inspection·January 4, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and policy review, the facility failed to timely address resident concerns. This affected one (#18) of one resident reviewed for concerns. The facility census was 56. Findings include: Review of the medical record for Resident #18 revealed an admission date of 03/01/23, with diagnoses of depression and morbid obesity. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. Review of the diet order dated 04/08/23 revealed Resident #18 received a regular diet with regular textures and thin liquids. Review of the current nutrition care plan revealed Resident #18 would benefit from weight loss. Review of the current care plan revealed Resident #18 planned to remain in long term care. Review of a nursing progress note dated 10/04/23 revealed Resident #18 expressed wanting to go on a diet to lose weight. Review of a nursing progress note dated 10/28/23 revealed Resident #18 stated he does not like this place and social services was notified. Review of the Nutrition Quarterly assessment dated [DATE] revealed Resident #18 would likely benefit from gradual weight loss. Review of a physician progress note dated 12/08/23 revealed Resident #18 complained about his weight and diet at the facility and thought the facility meals were the reason he was not losing weight. Interview on 01/02/24 at 10:03 A.M., with Resident #18 revealed he was unhappy at the facility. Resident #18 also stated he wanted to lose weight. Resident #18 stated he had talked to the Director of Social Services and the Registered Dietitian but neither provided any assistance or guidance. Interview on 01/03/24 at 10:12 A.M., with Director of Social Services (DSS) #513 revealed he felt Resident #18 was well adjusted in the facility. DSS #513 stated he was unaware of the progress note dated 10/28/23 wherein Resident #18 stated he did not like this place and did not address this concern with Resident #18. Telephone interview on 01/03/24 at 2:00 P.M., with Registered Dietitian #623 stated he visited the facility approximately one day per week and received consults from facility staff. RD #623 stated he did not receive any consults for weight loss diet education for Resident #18. RD #623 further stated he had not provided any weight loss diet education to Resident #18. Review of the policy titled Resident Concern Process, reviewed 12/31/22, revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 2 of 7 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 01/04/2024 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 0585 would review concerns and assign them for follow up and resolution. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 3 of 7 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 01/04/2024 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 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 observation, staff interview, record review, and policy review, the facility failed to have fall mats in place to reduce risk of injury if the resident falls out of bed. This affected one (#7) of one resident reviewed for falls. The facility census was 56. Findings include: Medical record review for Resident #7 revealed he was admitted on [DATE], with diagnoses of cognitive impairment and arthritis. Review of the quarterly Minimum Data Set (MDS) assessments dated 10/16/23 for Resident #7 revealed the resident is cognitively impaired. Review of the care plan dated December 2022 for Resident #7 revealed he was care planned for falls with the following interventions bilateral floor mates to each side of the bed and call light in reach. Observation on 01/03/24 at 8:31 A.M., of Resident #7 revealed the resident was lying in bed and fall mats were not in place to both sides of the bed. Observation on 01/03/24 at 4:19 P.M., of Resident #7 revealed the resident was lying in bed and the fall mats were not in place to both sides of the bed. Interview on 01/03/24 at 4:19 P.M., with Registered Nurse (RN) #549 confirmed the fall mats for Resident #7 were not in place to both sides of the bed. Review of the policy titled Fall Management Program Guidelines, dated May 2017 revealed the facility strives to maintain a hazard free environment and prevent implement preventative measures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 4 of 7 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 01/04/2024 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, staff interview, and review of the policy, the facility failed to ensure the provider addressed pharmacist recommendations. This affected one (#3) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record for Resident #3 revealed an admission date of 03/22/21, with diagnoses of atrial fibrillation (an irregular heart rhythm), and hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. Review of a current physician order dated 01/31/23 revealed Resident #3 received metoprolol tartrate 12.5 milligrams (mg) twice daily for atrial fibrillation. Review of a current physician order dated 01/31/23 revealed Resident #3 received sotalol tablet, 120 mg twice daily for atrial fibrillation. Review of the document Pharmacy Recommendations dated 07/24/23 revealed a recommendation to review a potential duplication in therapy with metoprolol and sotalol because both medications had similar actions. Interview on 01/04/24 at approximately 3:00 P.M., with the Director of Nursing (DON) confirmed the facility could not provide evidence the provider addressed the pharmacist's recommendation for Resident #3. Review of the policy titled, Pharmacy Services, revised Nonmember 2018, revealed pharmacist recommendations should be acted upon and documented by the facility personnel and/or the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 5 of 7 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 01/04/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure dietary staff used appropriate hand hygiene during food service. This affected three (#16, #46, and #48) residents and had the potential to affect all residents in the facility. The facility confirmed all residents received food from the kitchen. The facility census was 56. Findings include: Observation during meal service on 01/03/24 beginning at 11:56 A.M., revealed Dining Services Assistant Director (DSAD) #589 serving the noon meal. DSAD #589 prepared alternative menu items, including a [NAME] sandwich with fries, a cheeseburger with fries, and over-easy eggs with buttered bread. DSAD #589 was observed to wear plastic gloves on both hands while using the spatula to flip the burger and eggs, touching the fryer basket handle to pour out fries, and opening a plastic loaf of bread, pull out a slice of bread, hold the bread in his hand and butter the bread with his other hand, and place the bread on the plate with the over-easy eggs. DSAD #589 continued to wear the same pair of gloves to place an untoasted hamburger bun on a plate and use the spatula to put the burger on the bun, then use his gloved had to put the top bun on top of the burger. DSAD #589 was further observed to use the spatula to move the [NAME] sandwich from the grill, place it on a cutting board, and hold the sandwich with his left hand while cutting it in half with a knife. DSAD #589 then picked up the sandwich with both hands and placed half on a plate. Interview on 01/03/24 at approximately 12:11 P.M., with DSAD #589 confirmed he did not change his gloves between touching serving utensils and ready-to-eat food. The facility identified Resident #16 received the eggs with buttered bread, Resident #46 received the cheeseburger, and Resident #48 received the [NAME] sandwich. Review of the policy titled Food Production Guidelines, dated 05/13/16, revealed suitable utensils, such as forks, knives, tongs, or scoops shall be provided to minimize handling of food. The policy provided no guidance regarding the handling of ready-to-eat foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 6 of 7 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 01/04/2024 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** Based on medical record review, observation, staff interview and policy review, the facility failed to ensure hand hygiene was completed prior to the administration of eye medication. Additionally the facility failed to ensure staff properly transported soiled linen. This affected one (#50) of three residents reviewed for medication administration. This had the potential to affect 19 additional residents (#24, #25, #21, #44, #10, #22, #4, #2, #40, #48, #36, #39, #32, #8, #30, #6, #57, #28, #53) residing on the 100-hall. Residents Affected - Some Findings include Review of the medical record revealed Resident #50 had an admission date of 05/21/22. Diagnoses included Parkinson's disease, dementia, atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Observation on 01/03/24 at 8:50 A.M., revealed Licensed Practical Nurse (LPN) #543 administered oral medications to Resident #50. LPN #543 had not sanitized or washed her hands after administering the resident medications and touching the residents medication cup, bedside table and beverage cup with ungloved hands. LPN #543 then donned gloves and administered the resident Lotemax drops 0.5%, one drop in each eye. LPN #543 failed to wash or sanitize hands prior to donning gloves to administer the eye drop. Observation on 01/03/24 at 8:53 A.M., revealed LPN #543 picked up a soiled wet washcloth off of Resident #50's bedside table. LPN #543 carried the washcloth out of the room without first placing the washcloth in a bag. LPN #543 carried the washcloth down the 100-hall to the soiled utility room. Interview on 01/03/24 at 8:53 A.M., LPN #543 revealed she had not completed hand hygiene prior to the administration of the resident's eye drops. LPN #543 revealed she had not placed the soiled linen in a bag before transporting it through the hall. Interview on 01/03/24 at 10:17 A.M., the Director of Nursing (DON) revealed staff should bag soiled linens. The DON also verified staff should wash their hands or use hand sanitizer before putting on gloves. Review of policy titled Guidelines for Handling Linen, dated 05/11/16 revealed to place soiled linens in a plastic bag if wet or soiled with feces then discard soiled linen in soiled linen containers. Review of the policy titled Hand Hygiene, dated 01/18/23 revealed handwashing may also be used for routinely decontaminating hands before having direct contact with patients, before and after preparing medication, and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Review of the policy titled Medication Administration: General Guidelines, last revised Nonmember 2018, revealed handwashing or hand sanitization would be completed before and after administration of ophthalmic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365663 If continuation sheet Page 7 of 7