Health inspection·October 12, 2021

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 10/04/21, 10/05/21, 10/06/21, and 10/07/21, revealed all residents in the main area of the facility were served breakfast and lunch in their rooms. Residents Affected - Some Interview on 10/06/21 at 11:03 A.M. with Dietary Assistant #362 and Dietary Assistant #369 revealed the resident's have been eating in their rooms since August due to the dining room chairs being broken. Both Dietary Assistants stated the memory care unit dining room was open. Interview on 10/06/21 at 1:10 P.M. with Director of Nursing (DON) revealed the facility has not had a chance to implement the resident's returning to the dining room and the facility is in the process of working with dietary to get an open dining concept started. Interviews on 10/06/21 at 3:00 P.M. and 3:10 P.M. with Resident #26 and Resident #219 revealed they were not aware the dining room was open to eat. Resident #219 stated she thought the dining room was closed due to coronavirus (COVID-19). Interview on 10/07/21 at 10:27 A.M. with Maintenance #376 revealed some of the dining room chairs in the main dining room were broken and needed to be repaired. Maintenance #376 stated the Administrator ordered new chairs. Interview on 10/07/21 at 4:00 P.M. with Dietary Manager #365 revealed the main dining room has been closed since July 2021. Dietary Manager #365 stated some of the dining room chairs are broken and the facility is working on opening the dining room again. Observation on 10/07/21 at 1:20 P.M. of the main dining room revealed 11 tables and 18 dining room chairs, one of the chairs had a broken arm. Interview on 10/07/21 at 2:06 P.M. with the Administrator revealed before COVID-19 every resident went to the dining room and now there are about eight residents who would utilize the dining room for meals. The Administrator verified the memory care unit's dining room is open and residents were being served in the dining room. Interview on 10/07/21 at 2:33 PM with Resident #223 revealed he would like to go the dining room if it was open. Review of facility policy titled Serving Meals undated, revealed the presentation of the meal directly affects how much the resident eats. Presentation includes the dining environment, the attitude of the server, and the appearance of the table or room tray. All residents are encouraged to eat in the dining room. Based on observation, resident and staff interview, and review of facility policy the facility failed to ensure call lights were accessible to residents. This affected one (#53) resident reviewed for call lights. In addition, the facility failed to have the dining room available for dining service. This affected three (#26, #219, and #223) residents reviewed for dining services. The facility census was 78. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 2 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Review of Resident #53's medical record revealed an admission date of 11/22/18 and a readmission date of 01/06/21. Diagnoses included chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and spinal stenosis. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #53 was mildly cognitively impaired. Observation on 10/04/21 at 11:16 A.M. of Resident #53 revealed the Resident was sitting in her recliner, which was positioned approximately halfway down the wall. To the left of the recliner was a table and the Resident's bed was on the other side of the table. The bed was positioned lengthwise, with the head of the bed on the same wall as the Resident's recliner. The call light was observed to be rolled in a coil and hanging on the call light wall unit on the wall to the left and near the foot of the bed. A call light was not observed to be within reach of Resident #53. Interview on 10/04/21 at 11:16 A.M. of Resident #53 revealed she did not have access to a call light. Resident #53 stated if she needed assistance, she had to ask her roommate to push her call light. Resident #53 stated her roommate did not always hear her and she sometimes had to wait until someone walked by. Resident #53 stated You would think they would have one closer to me since I always sit in my recliner. Observation on 10/05/21 at 8:46 A.M. of Resident #53 revealed the Resident was sitting up in bed eating breakfast. Resident #53's call light was not observed within reach of the Resident. When asked about her call light, Resident #53 pointed to the call light, rolled in a coil and hanging on the wall near the foot of the bed, and stated it's hanging there. Observation on 10/05/21 at 11:02 A.M. of Resident #53 revealed the Resident was sitting in her recliner. The call light was observed to be hanging on the wall near the foot of the bed. Interview of Resident #53 at the time of the observation revealed she had no way to call for staff assistance except to ask her roommate to push her call light or wait for someone to walk by. Interview on 10/05/21 at 11:24 A.M. of State Tested Nurse Aide (STNA) #351 revealed call lights should be attached to a resident's chair, bed, or close enough to the resident so they can reach it. STNA #351 verified Resident #53 did not have a call light accessible to her. STNA #351 stated Resident #53's bed was previously positioned on the wall, next to the call light but stated the call light wall unit, located to the right of Resident #53's recliner, should have two call light cords, one to attach to Resident #53's recliner and one for her roommate. STNA #53 moved the privacy curtain between Resident #53's recliner and her roommate's bed, reached behind Resident #53's recliner, and found a second call light cord. STNA #53 attached the call light to Resident #53's chair and noted the cord would not reach Resident #53's bed. STNA #351 removed the coiled call light from the wall near the foot of Resident #53's bed, placed it on Resident #53's bed and stated she would find a clip to secure it to the Resident's bed because it would slide off otherwise. Review of facility policy titled Call Light, Use of, dated February 2015, revealed when providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 3 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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, resident interview, staff interview, and review of facility policy, the facility failed to report allegations of misappropriation. This affected one (Resident #5) of two residents reviewed for personal property. The facility census was 78. Residents Affected - Few Findings Include: Review of Resident #5's medical record revealed an admission date of 10/06/15 and a readmission date of 01/13/21. Diagnoses included multiple sclerosis, type two diabetes, and major depression. Review of Resident #5's Minimum Data Set, dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 displayed no behaviors during the review period. Review of Resident #5's inventory list dated 05/27/21 revealed Resident #5 had four cameras noted on his inventory list. Review of the facility's Self Reported Incidents (SRIs) revealed no incident was reported for the missing camera and camera accessories. Review of Resident #5's progress notes revealed no documented report of Resident #5's missing a camera. Interview on 10/06/21 at 2:12 P.M. with Resident #5 revealed Resident #5 had a camera bag with a camera, two camera lenses, and three filters stolen from his room. Resident #5 stated he reported the missing camera bag and photography equipment to the Administrator twice and nothing was done about it on either occasion. Resident #5 stated his camera was on his inventory of possessions when he came to the facility. He reported the Administrator told him it would not be replaced because he had not identified the model of camera on the inventory so they could not prove he even had it. Resident #5 reported they didn't even look for it. He stated he used to be professional photographer and had a Cannon single lens reflex digital camera, two camera lenses for photographing different distances and three filters for softening light and adding effects that were all missing. Resident #5 stated he expected to file a police report for his missing items but he never heard anything more after talking with the Administrator. Interview on 10/06/21 at 3:31 P.M. with the Administrator verified Resident #5 reported his camera missing. The Administrator stated Resident #5 had a history of fabricating things and was having a psychiatric episode when he alleged his camera was missing. The Administrator reported Resident #5 was sent out for psychiatric stabilization and when he returned the type of camera he reported missing had changed. The Administrator reported Resident #5 had four cameras listed on his inventory but stated there was no evidence he had the items he was alleging he was missing. The Administrator stated there was a credibility issue with Resident #5 and he declined filing a police report even though he had alleged the camera was worth $4000. Review of the facility investigation revealed Resident #5 reported his camera missing on 08/17/21. Resident #5 went out to the hospital for mental health stabilization, returned to the facility on [DATE], and on 09/27/21 Resident #5 was interviewed and again reported his camera missing. Resident #5's inventory was reviewed and four cameras were listed as being in his possession on 05/27/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 4 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 Statements were taken from Resident #5, Social Service Director (SSD) #382 and the Administrator. Staff and other residents were interviewed regarding missing items. No self-reported incident was submitted for the allegation of misappropriation. Interview on 10/07/21 at 9:26 A.M. with the Administrator revealed she was investigating two other allegations of misappropriation on the 200 hallway at the time of Resident #5's alleged missing camera. Residents and staff were interviewed regarding missing items. The Administrator verified an SRI was not completed for Resident #5's camera as they did not feel his allegation was credible due to his history or fabrication, exaggeration, and cycling mental health. The Administrator verified the allegation of misappropriation was not reported as outlined in their abuse policy. Review of the undated facility policy titled, Abuse Prevention, Intervention, Investigation, and Crime Reporting, revealed the purpose of the policy was to protect the psychosocial, physical wellbeing and personal possessions of residents. It was a requirement that reporting happened within two hours or as soon as practically possible after notification of suspected misappropriation of resident property to the Ohio Department of Health, and local law enforcement as appropriate. Review of the undated facility policy titled, Abuse Prevention, Intervention, Investigation, and Crime Reporting, revealed the purpose of the policy was to protect the psychosocial, physical wellbeing and personal possessions of residents. It was a requirement that reporting happened within two hours or as soon as practically possible of notification of suspected misappropriation of resident property to the Ohio Department of Health, and local law enforcement as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 5 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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, resident interview, staff interview, and review of facility policy, the facility failed to report allegations of misappropriation. This affected one (Resident #5) of two residents reviewed for personal property. The facility census was 78. Findings Include: Review of Resident #5's medical record revealed an admission date of 10/06/15 and a readmission date of 01/13/21. Diagnoses included multiple sclerosis, type two diabetes, and major depression. Review of Resident #5's Minimum Data Set, dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 displayed no behaviors during the review period. Review of Resident #5's inventory list dated 05/27/21 revealed Resident #5 had four cameras noted on his inventory list. Review of the facility's Self Reported Incidents (SRIs) revealed no incident was reported for the missing camera and camera accessories. Review of Resident #5's progress notes revealed no documented report of Resident #5's missing a camera. Interview on 10/06/21 at 2:12 P.M. with Resident #5 revealed Resident #5 had a camera bag with a camera, two camera lenses, and three filters stolen from his room. Resident #5 stated he reported the missing camera bag and photography equipment to the Administrator twice and nothing was done about it on either occasion. Resident #5 stated his camera was on his inventory of possessions when he came to the facility. He reported the Administrator told him it would not be replaced because he had not identified the model of camera on the inventory so they could not prove he even had it. Resident #5 reported they didn't even look for it. He stated he used to be professional photographer and had a Cannon single lens reflex digital camera, two camera lenses for photographing different distances and three filters for softening light and adding effects that were all missing. Resident #5 stated he expected to file a police report for his missing items but he never heard anything more after talking with the Administrator. Interview on 10/06/21 at 3:31 P.M. with the Administrator verified Resident #5 reported his camera missing. The Administrator stated Resident #5 had a history of fabricating things and was having a psychiatric episode when he alleged his camera was missing. The Administrator reported Resident #5 was sent out for psychiatric stabilization and when he returned the type of camera he reported missing had changed. The Administrator reported Resident #5 had four cameras listed on his inventory but stated there was no evidence he had the items he was alleging he was missing. The Administrator stated there was a credibility issue with Resident #5 and he declined filing a police report even though he had alleged the camera was worth $4000. Review of the facility investigation revealed Resident #5 reported his camera missing on 08/17/21. Resident #5 went out to the hospital for mental health stabilization, returned to the facility on [DATE], and on 09/27/21 Resident #5 was interviewed and again reported his camera missing. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 6 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 #5's inventory was reviewed and four cameras were listed as being in his possession on 05/27/21. Statements were taken from Resident #5, Social Service Director (SSD) #382 and the Administrator. Staff and other residents were interviewed regarding missing items. No self-reported incident was submitted for the allegation of misappropriation. Interview on 10/07/21 at 9:26 A.M. with the Administrator revealed she was investigating two other allegations of Misappropriation on the 200 hallway at the time of Resident #5's alleged missing camera. Residents and staff were interviewed regarding missing items. The Administrator verified an SRI was not completed for Resident #5's camera as they did not feel his allegation was credible due to his history or fabrication, exaggeration, and cycling mental health. Review of the undated facility policy titled, Abuse Prevention, Intervention, Investigation, and Crime Reporting, revealed the purpose of the policy was to protect the psychosocial, physical wellbeing and personal possessions of residents. It was a requirement that reporting happened within two hours or as soon as practically possible after notification of suspected misappropriation of resident property to the Ohio Department of Health, and local law enforcement as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 7 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 0685 Assist a resident in gaining access to vision and hearing services. 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, resident interview, staff interview and review of resident council minutes, the facility failed to ensure residents received vision services in a timely manner. This affected one (Resident #32) of two residents reviewed for vision services. The facility census was 78. Residents Affected - Few Findings Include: Review of Resident #32's medical record revealed an admission date of 03/13/21. Diagnoses included type two diabetes, major depressive disorder, and anxiety disorder. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. Review of Resident #32's Health Care Services Consent Form dated 03/22/21 revealed Resident #32 accepted optometry services. Review of Resident #32's progress notes and scanned documents revealed Resident #32 had no vision appointments completed or scheduled. Interview on 10/04/21 at 10:04 A.M. with Resident #32 revealed she had been in the facility since March 2021, had concerns with her vision, had signed the consent for services, and had not yet been seen by the eye doctor. Interview on 10/06/21 at 8:23 A.M. with Social Services Director (SSD) #382 verified Resident #32 signed a consent to receive vision services through the facility but was not aware of when Resident #32 was scheduled for an appointment. Interview on 10/07/21 at 9:17 A.M. with SSD #382 verified Resident #32 had not been seen by vision services since her admission. Review of the Resident Council Meeting Minutes revealed residents expressed concerns regarding lack of vision appointments in April 2021, July 2021, and September 2021. The response from social services was that an that the eye doctor was in the facility in March 2021 with no date provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 8 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident observation, and staff interview, the facility failed to ensure pressure relieving devices were in place as ordered by the physician. This affected one (Resident #15) of one resident reviewed for pressure ulcers. The facility census was 78. Residents Affected - Few Findings Include: Review of Resident #15's medical record revealed an admission date of 07/08/21. Diagnoses included chronic kidney disease, diabetes with foot ulcer, and muscle wasting and atrophy. Review of Resident #15's Minimum Data Set assessment dated [DATE] revealed the resident had intact cognition. The assessment listed the resident as at risk for pressure ulcers. Review of Resident #15's most recent care plan revealed the resident had actual pressure ulcers to the left heel, right heel, left lateral ankle, and left medial foot. Interventions included to provide a pressure redistribution therapeutic device as ordered. Review of Resident #15's physician order dated 09/28/21 revealed an order for off-loading bilateral heel boots every day and night shift for wound healing. Use z-flex [NAME], a off-loading heel boot, until heelmedix boots, a off-loading heel boot, arrive. Review of Resident #15's Treatment Administration Record (TAR) dated 10/05/21 and 10/06/21 revealed the resident did not refuse the ordered bilateral heel boots. Observation on 10/05/21 at 1:59 P.M. of Resident #15 revealed no off-loading heel boots were in place. The resident stated there was a wound on his heel. Interview on 10/05/21 at 2:12 P.M. with Licensed Practical Nurse (LPN) #325 verified Resident #15 did not have off-loading boots in place to bilateral heels as ordered. LPN #325 looked for the residents z-flex boots and found the boots in the resident's closet. Interview on 10/05/21 at 2:12 P.M. with Resident #15 revealed he did not refuse to wear the boots. Observation on 10/06/21 at 8:44 A.M. of Resident #15 revealed the resident did not have the off-loading bilateral heel boots in place. Interview on 10/06/21 at 8:44 A.M. with LPN #325 verified the heel boots were not in place as ordered. This deficiency substantiates Complaint Number OH00110803. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 9 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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** 2. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease, dementia with behaviors, depression, and vitamin D deficiency. Review of Resident #10's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognitive skills and no abnormal behaviors. Review of Resident #10's physician orders revealed the resident was ordered valproic acid, a mood stabilizer, delayed release 125 milligrams by mouth twice daily, and ergocalciferol, a vitamin D supplement, 50,000 units by mouth daily. Review of Resident #10's physician order dated 02/06/19 revealed Risperdal (anti-psychotic medication) 0.25 milligrams by mouth was to be given three times daily. Review of Medication Administration Records dated 10/2021 and 11/2021 revealed the resident received the depakote, risperdal, and vitamin D as ordered. Review of Resident #10's pharmacist recommendation form dated 04/22/21 revealed the pharmacist recommended for a valproic acid level to be drawn every six months. The physician agreed with the recommendation, however the recommendation was not addressed until 06/02/21 and was signed on 07/16/21. Review of Resident #10's pharmacist recommendation form dated 04/22/21 revealed the consultant pharmacist recommended a semi-annual evaluation for continued use of the Risperdal 0.25 mg by mouth three times daily. The recommendation was addressed and signed by the physician on 07/16/21. Review of Resident #10's pharmacist recommendation form dated 05/21/21 revealed the pharmacist recommended for a Vitamin D level to be drawn every six months. The recommendation form was marked as agree and was signed by the physician on 07/16/21. Interview with the DON on 10/06/21 at 9:22 A.M. verified the pharmacist recommendation's were not addressed and signed by the physician in a timely manner. Interview with the DON on 10/06/21 at 9:45 A.M. verified the physician recommendation forms have been behind. She stated she took over the position of DON in 03/2021 and in 05/2021 discovered the physician recommendation forms had not been acted upon and discussed the issues with the pharmacist. The interview further verified the pharmacist recommendation forms were not addressed in a timely manner. Review of facility policy Medication Regimen Review dated 08/2020 revealed the consultant pharmacist was to perform a comprehensive review of each resident's medicate regimen and clinical record at least monthly. The medication regimen review was to include evaluation of the resident's response to medication therapy to determine if the resident maintained the highest practicable level of functioning and prevention or minimalization of adverse reactions to medication therapy. The recommendations were to be acted upon and documented by the facility staff and/or prescriber. The policy did not include the time parameter for the physician to respond. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 10 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 Based on medical record review, review of pharmacy recommendations, review of pharmacy email correspondence, staff interview, and review of the facility policy, the facility failed to ensure pharmacy recommendations were reviewed timely by the physician. This affected two (#10 and #49) of five residents reviewed for pharmacy recommendations. The facility census was 78. Residents Affected - Few Findings include: 1. Review of Resident #49's medical record revealed an admission date of 10/17/19 and a readmission date of 07/17/21. Diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and occlusion and stenosis of unspecified carotid artery. Review of a physician order dated 08/01/21 revealed Resident #49 was prescribed clopidogrel bisulfate tablet, an antiplatelet medication, 75 milligrams (mg) one tablet by mouth in the morning. Review of the Medication Administration Record (MAR) from 08/01/21 through 10/06/21 revealed Resident #49 received clopidogrel bisulfate tablet 75 mg as ordered. Review of a pharmacy recommendation form dated 08/19/21 revealed Resident #49 was prescribed Plavix with a recommendation to consider discontinuing Plavix. Further review of the pharmacy recommendation form revealed the physician agreed with the recommendation and did not review the recommendation until 09/30/21. Review of a pharmacy email correspondence dated 08/19/21 revealed the August 2021 pharmacy review and recommendations were sent to the Director of Nursing (DON) on 08/19/21. Interview on 10/06/21 at 9:17 A.M. with the DON revealed pharmacy recommendations were received via email then printed and placed on the physician's board for review. The DON stated the pharmacy was always a month behind so she did not receive the August 2021 pharmacy recommendations until September 2021. The DON verified the email from the pharmacy for the 08/19/21 pharmacy review was sent to her from the pharmacy on 08/19/21 and the physician did not review the recommendation until 09/30/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 11 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for the Resident #70 revealed an admission date of 01/15/21 and discharge date of 02/25/21. Diagnoses included metabolic encephalopathy, pneumonia, chronic atrial fibrillation, and dysphagia. Residents Affected - Few Review of Resident #70's physician order with a start date of 01/31/20 revealed daptomycin solution intravenously 338 (MG) milligrams was ordered one time a day related to bacteremia pneumonia. The order had an end date of 02/16/20. Review of the incident audit report dated 02/10/20 revealed the wrong intravenous (IV) antibiotic, Vancomycin, was running through Resident #70's IV before it was recognized as medication error. License Practical Nurse #325 stopped the IV, flushed the IV with normal saline and heparin, took a set of vitals, ensured the patients safety, then notified the Certified Nurse Practitioner (CNP) and contacted the pharmacy. The CNP stated to monitor Resident #70's vital signs for increased signs and symptoms of infection and run the scheduled dose of Daptomycin. Interview on 10/07/21 at 3:23 P.M., with License Practical Nurse (LPN) #325 revealed when taking the medication from the refrigerator the label was crinkled. LPN #325 stated she did not read the label clearly and continued to hang the antibiotic. Once the antibiotic was running the IV machine started beeping and she went back to check on the IV, at which time she realized she hung the wrong antibiotic. The interview further revealed the guardian was in the room and was made aware of the medication error right away. The CNP was called and instructed staff to monitor Resident #70's vital signs as well as monitor for increase in signs and symptoms of infection. Review of the facility policy titled General Guidelines for Medication Administration, revision date 08/2020, revealed at a minimum, the five rights, the right resident, right drug, right dose, right route, and right time, should be applied to all medications administration and reviewed at three steps in the process of preparation: (1) Select the medication check the label, container, and contents for integrity, and compare the medication against the Medication Administration Record (MAR) by reviewing the five rights. (2) prepare the dose by removing the dose from the container and verifying it against the label and the MAR by reviewing the 5 rights. (3) complete the preparation of the dose and re-verify the label against the MAR by reviewing the five rights. Additionally, medications are administered in accordance with written orders of the prescriber. This deficiency substantiates Complaint Number OH00114252, Complaint Number OH00110841, and Complaint Number OH00110803. Based on medical record review, review of a pharmacy recommendation form, staff interview, and review of facility policy the facility failed to provide medications as ordered by the physician. This affected two (#49 and #70) of four residents reviewed for medication administration. The facility census was 78. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 10/17/19 and a readmission date of 07/17/21. Diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and occlusion and stenosis of unspecified carotid artery. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 12 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the significant change Minimum Data Set, dated [DATE] revealed Resident #49 was severely cognitively impaired. Review of the plan of care revised 09/23/21 revealed Resident #49 was at high risk for abnormal bleeding due to anticoagulant (medications used to prevent blood clots) therapy. Interventions included administer medications as prescribed by the physician. Review of physician order dated 08/01/21 revealed Resident #49 was prescribed apixaban (Eliquis) tablet, a medication to help prevent blood clots, five milligrams (mg) by mouth two times a day and clopidogrel bisulfate (Plavix) tablet, an antiplatelet medication, 75 mg one tablet by mouth in the morning. Review of a pharmacy recommendation form dated 08/19/21 revealed Resident #49 was receiving Plavix and Eliquis. According to the manufacturer, this combination was not recommended as there was an increased risk of bleeding when taken together. Please weigh the benefits versus the risks for continued use and consider discontinuing the Plavix. Additional review of the pharmacy recommendation form revealed on 09/30/21 the physician agreed with the recommendation and discontinued the Plavix. Review of the Medication Administration Record (MAR) from 10/01/21 through 10/06/21 revealed Resident #49 was administered clopidogrel bisulfate (Plavix) tablet 75 mg on 10/01/21, 10/02/21, 10/03/21, 10/04/21, and 10/06/21. The MAR revealed Resident #49 refused the medication on 10/05/21. Interview on 10/06/21 at 9:11 A.M. of Licensed Practical Nurse (LPN) #384 verified clopidogrel bisulfate tablet (Plavix) 75 mg was still an active order for Resident #49 and was being administered daily. Interview on 10/06/21 at 9:17 A.M. of the Director of Nursing (DON) verified clopidogrel bisulfate (Plavix) was still an active order being administered to Resident #49 and the physician discontinued the medication on 09/30/21. The DON stated she reviewed the physician order yesterday (10/05/21) and thought it had been discontinued. The DON stated nursing should review physician orders and make sure any changes were updated in the resident's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 13 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 interview, and review of facility policy, the facility failed to ensure laboratory tests were completed as ordered. This affected one (Resident #10) of five residents reviewed for unnecessary medications. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, depression, and vitamin D deficiency. Review of a physician recommendation form dated 05/21/21 revealed the resident received Vitamin D 50,000 units by mouth. A recommendation was made to the physician by the pharmacist for a Vitamin D level to be drawn every six months. The recommendation form to check a Vitamin D level was marked as agree by the physician and was signed by the physician on 07/16/21. Review of physician orders dated 02/14/19 revealed Resident #10 was to receive Ergocalciferol (Vitamin D), 50,000 units by mouth once weekly. The medication was reordered on 07/19/21. Review of Medication Administration Records dated 09/2021 and 10/2021 revealed Resident #10 received the Vitamin D supplement as ordered. Interview with the Director of Nursing (DON) on 10/06/21 at 9:22 A.M. verified the Vitamin D blood level had not been drawn as the physician agreed to on 07/16/21. She stated she was going to call the physician to see if the Vitamin D level was still desired and if it was, they would obtain a new order. Review of an undated facility policy titled Request for Diagnostic Services revealed all requests for diagnostic services must be ordered by a physician. The orders were to be carried out as instructed by the physician's order. This deficiency substantiates Complaint Number OH00110803. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 14 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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, resident interview, staff interview, the facility failed to ensure residents received timely dental services. This affected one (Resident #32) of two residents reviewed for dental services. The facility census was 78. Residents Affected - Few Findings Include: Review of Resident #32's medical record revealed an admission date of 03/13/21. Diagnoses included type two diabetes, major depressive disorder, and anxiety disorder. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. Review of Resident #32's care plan revised 06/15/21 revealed supports and interventions for self-care deficit, resistance to care, impaired cognitive function, depression, and potential for oral/dental health problems. Review of Resident #32's Health Care Services Consent Form dated 03/22/21 revealed Resident #32 accepted dentistry services. Review of Resident #32's progress notes and scanned documents revealed Resident #32 had no dental appointments completed or scheduled. Interview on 10/04/21 at 10:04 A.M. with Resident #32 revealed she had been in the facility since March 2021, had concerns with her teeth and gums, signed the consent for services, and had not yet been seen by the dentist. Interview on 10/06/21 at 8:26 A.M. with Social Services Director (SSD) #382 verified Resident #32 signed a consent to receive dental services through the facility but was not aware of when Resident #32 was scheduled for an appointment. Interview on 10/07/21 at 9:17 A.M. with SSD #382 verified Resident #32 had not been seen by dental services since her admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 15 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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, staff observation, staff interviews, review of facility policy, and review of Centers for Disease and Control (CDC) guidelines, the facility failed to ensure staff followed infection control guidelines and all required Personal Protective Equipment (PPE) had been utilized during the coronavirus 2019 (COVID-19) pandemic to prevent transmission of the virus. The county positive rate was listed as high. The practice had the potential to affect all residents residing in the facility. The facility census was 78. Residents Affected - Many Findings include: 1. Review of Resident #222's medical record revealed an admission date of 09/28/21. Diagnoses included COVID-19, congestive heart failure, and hypertension. Review of Resident #222's COVID-19 test dated 09/24/21 revealed the resident tested positive for COVID-19. Observation on 10/04/21 at 12:06 P.M. revealed Resident #222 was in an isolation room. There was no signage observed outside of the resident's room indicating the resident was under isolation precautions. Interview on 10/04/21 at 12:15 P.M. with Registered Nurse (RN) #378 verified Resident #222 was under isolation precautions for COVID-19 and did not have signage indicating the type of isolation the resident was on and the required PPE. 2. Observation on 10/04/21 at 10:55 A.M. of an outside contractor working in the main dining room on a door revealed the contractor did not have a face mask or eye protection in place. Interview iwth the Director of Nursing (DON) on 10/04/21 at 10:55 A.M. verified the contractor should be wearing an N-95 respirator and eye protection. 3. Observation on 10/07/21 at 9:28 A.M. of Licensed Practical Nurse (LPN) #312 revealed LPN #312 was administering medications to residents with only a surgical mask and eye protection in place. Interview on 10/07/21 at 9:40 A.M. with DON verified LPN #312 had a surgical mask in place and not an N95 respirator. The DON stated LPN #312 had a physician note to wear a surgical mask. Review of LPN #312 physician note dated 10/26/20 revealed LPN #312 may wear a surgical mask instead of a N-95 respirator while not providing direct patient care as long as there are no positive COVID-19 patients in the building. Review of the facility COVID-19 positive residents on 10/07/21 revealed one COVID-19 positive resident (#324) in the facility at the time of the above observation. 4. Review of Resident #324's medical record revealed an admission date of 10/05/21. Diagnoses included COVID-19, pneumonia due to coronavirus, and dementia. Review of Resident #324's COVID-19 test dated 09/30/21 revealed a COVID-19 positive result. Observation on 10/07/21 at 2:11 P.M. of State Tested Nursing Assistant (STNA) #311 revealed STNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 16 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 #311 was in Resident #324's room and was not wearing the proper PPE. STNA #311 was wearing an N-95 respirator and eye protection. STNA #311 was not wearing an isolation gown or gloves. STNA #311 stated she was not aware the resident was COVID-19 positive and verified she should have been wearing an isolation gown and gloves. 5. Observation on 10/05/21 at 2:54 P.M. of the DON revealed the DON completed a COVID-19 rapid test for LPN #377. The DON did not wear an isolation gown while conducting the COVID-19 test on LPN #377. No isolation gowns were observed in the testing area. Interview on 10/05/21 at 2:54 P.M. of the DON revealed full PPE was only to be worn during outbreak testing. 6. Observation on 10/04/21 at 10:57 A.M. of Physical Therapy Assistant (PTA) #387 revealed PTA #387 was pushing Resident #271 down the hall in a wheelchair. PTA #387 stopped across from the 100 hall nurses' station, left Resident #271 sitting in the hall, walked to the nurses station, and proceeded down the 100 hall. PTA #387's N-95 respirator was positioned under his nose and mouth during the entire observation. Interview on 10/04/21 at 10:59 A.M. of PTA #387 verified his N-95 respirator was positioned under his nose and mouth. PTA #387 stated the N-95 slid down sometimes and he would have to readjust it. 7. Observation on 10/05/21 at 10:52 A.M. of the main dining room revealed Residents #16, #25, #34, #47, and #48 participating in BINGO. Activities Assistant (AA) #356 was observed with her N-95 respirator positioned below her nose and mouth and her face shield positioned on top of her head, exposing her eyes, nose, and mouth. AA #356 was calling the BINGO numbers for the activity. AA #356 positioned her N-95 back over her nose and mouth when she noticed the surveyor but did not adjust her face shield. Interview on 10/05/21 at 10:55 A.M. of the DON verified AA #356's face shield was not positioned to cover her eyes, nose, and mouth and stated the face shields were not the easiest to see through. Interview on 10/05/21 at 12:22 P.M. of AA #356 verified, during the BINGO activity, her N-95 respirator was pulled down under her nose and mouth, and her face shield was placed on top of her head. Review of facility policy titled Best Practice Guideline, dated December 2020, revealed the type of PPE should be appropriate for the procedure being performed and the type of exposure anticipated. Review of Centers for Medicare and Medicaid Services Nursing Home Data revealed for the week of 10/05/21, [NAME] county was classified as red and had a 14 day positivity rate of 12.0%. Review of CDC Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, last updated 02/26/21 and found at https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html, revealed For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended PPE, which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. Review of the Centers for Medicare and Medicaid Services memo titled QSO-20-38-NH revealed that facilities must demonstrate compliance with the testing requirements. To do so, facilities should do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 17 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 the following: During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 18 of 19 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to ensure resident bathrooms were free of peeling paint. This affected two (#24 and #29) of two residents reviewed for physical environment. The facility census was 78. Findings include: 1. Observation on 10/04/21 at 10:10 A.M. of Resident #24's bathroom revealed an approximately three inch area of peeling paint under the wall register vent, peeling paint along the top of the register vent, and an approximately 2 inch area of peeling paint to the lower left of the vent. 2. Observation on 10/04/21 at 11:10 A.M. of Resident #29's bathroom revealed an area approximately 12 inches long and three inches wide of peeling paint located on the wall between the sink and wall register vent. Interview on 10/04/21 3:47 P.M. of Licensed Practical Nurse (LPN) # 345 verified the peeling paint in Resident #24 and #29's bathrooms. Interview on 10/06/21 at 7:55 A.M. of Maintenance Supervisor (MS) #376 revealed he was aware of the peeling paint in Resident #24 and #29's bathrooms. MS #376 stated he was the only maintenance staff at the facility, the corporate office did not want to hire someone to paint, and he would get to it whenever he had time. MS #376 stated he did not know when he would have time to make the needed repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 19 of 19