Health inspection·September 6, 2023

F 0561 shower even though Resident #1 refused. Level of Harm - Minimal harm or potential for actual harm Interview on 09/05/23 at 10:21 A.M. with State Tested Nursing Assistant (STNA) #127 verified she was witness to the interaction on 08/23/23 between Resident #1 and STNA #145 and heard Resident #1 say she did not want to shower. STNA #127 reported Resident #1 had the right to refuse and STNA #145 should have respected the refusal instead of trying to push her into the shower room. Residents Affected - Few Review of the facility policy titled, Resident Rights, revised September 2022 revealed employees were to treat all residents with kindness, respect and dignity. Resident rights included the right to self-determination. This deficiency represents non-compliance investigated under Complaint Number OH00145986. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 2 of 6 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 09/06/2023 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 a physical restraint was not used as a behaviorial intervention without a physician order, prior assessment, or care plan support. This affected one (Resident #3) of three residents reviewed for restraints. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed an admission date of 11/02/22 and a readmission date of 01/23/23. Diagnoses included dementia with behavioral disturbance, multiple myeloma, anemia, and anxiety disorder. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating Resident #3 was moderately cognitively impaired. Resident #3 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #3 displayed no behaviors at the time of the review. Review of Resident #3's care plan revised 09/02/23 revealed supports and interventions in place for risk for impaired skin integrity, self-care deficit, and behaviors. Resident #3's behaviors included being physically and verbally aggressive toward others, being resistant to care, and putting self on the ground. Interventions included approach Resident #3 in a calm manner to avoid frustration and behavior escalation, attempt to redirect Resident #3 when exhibiting behaviors, re-approach when Resident #3 has deescalated, and keep Resident #3 safe during episodes of behaviors, attempt to redirect. Resident #3 had no behavior interventions for use of a Broda chair (geriatric chair). In addition, Resident #3 had supports and interventions in place for impaired psychiatric status, which included administering medications as ordered, assisting Resident #3 to cope by discussing possible solutions to conflict, behavioral health consult as needed, offer Resident #3 choices whenever possible in order to promote a feeling of self-worth and control over her environment. Review of Resident #3's physician orders revealed no order for the use of a Broda chair. Review of Resident #3's Restraint Enabler Decision Tree (REDT) dated 02/27/23 revealed Resident #3 had a wheelchair for mobility. Resident #3's REDTs dated 08/03/23 revealed Resident #3 was able to have her bed against the wall to prevent falls, a perimeter mattress to prevent falls, pommel cushion to prevent falls, and a dumped wheelchair (custom wheelchair sloping down toward the back) to prevent falls. Resident #3 had no REDT for the use of a Broda Chair. Review of Resident #3's progress notes revealed on 07/29/23 at 4:57 P.M. it was noted Resident #3 was very combative. She was hitting staff and throwing things. She was also verbally abusive to other residents and staff. On 07/29/23 at 10:49 P.M. it was noted Resident #3 was yelling and screaming. Resident #3 threw herself on the floor mat several times. Licensed Practical Nurse (LPN) #167 and State Tested Nursing Assistant (STNA) #135 placed Resident #3 in a Broda chair (geriatric chair) for safety. Resident #3 was noted to be sitting in the Broda chair in the dining room for one-on-one supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 3 of 6 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 09/06/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/30/23 at 3:08 A.M. it was noted Resident #3 remained in the Broda chair yelling and tearing off band aides on her knuckles. She was unable to be redirected. Review of the Resident #3's one-on-one sign off sheets for 07/29/23 and 07/30/23 revealed Resident #3 was in the Broda chair and receiving one-on-one supervision from 11:00 P.M. on 07/29/23 to 4:00 A.M. on 07/30/23 when Resident #3 was laid back in bed. Resident #3 was in the Broda chair for approximately five hours. Interview on 09/05/23 at 10:29 A.M. with Licensed Practical Nurse (LPN) #167 verified she worked the night when Resident #1 was put in the Broda chair. LPN #167 reported Resident #3 was throwing herself on the floor mat in her room and almost hit her head. She was transferred to an extra Broda Chair and taken to the common area, which served as the activity room and dining room as well. LPN #167 reported Resident #3 was not able to walk or bear weight, but was able to propel herself in her personal wheelchair and transfer herself between her wheelchair and bed. LPN #167 verified Resident #3 did not have a Broda chair that belonged to her, did not regularly use a Broda chair, and verified Resident #3 was not able to propel herself in the Broda chair. Interview on 09/05/23 at 1:34 P.M with the Administrator verified there was no order for Resident #3 to have a Broda chair. The Broda chair that was used for Resident #3 belonged to another resident on the hallway. The Administrator reported Resident #3 had one-on-one supervision for the entire time she was in the Broda chair and the other resident's Broda chair was used as an emergency intervention to keep Resident #3 safe. The Administrator verified Resident #3 was in the Broda chair from approximately 11:00 P.M. on 07/29/23 until 4:00 A.M. on 07/30/23 when she was transferred into bed. Interview on 09/05/23 at 2:41 P.M. with STNA #135 verified she was working on 07/29/23, and assisted with placing Resident #3 in the other resident's Broda chair. STNA #135 reported Resident #3 was throwing herself out of bed and onto the mat on her floor. Resident #3's skin was thin, and to keep her safe, they placed her in the other resident's Broda chair and moved her into the dining room with them so she could be monitored. STNA #135 reported Resident #3 was seated upright in the chair, had no foot rests in place, and was not able to get herself out of the Broda chair. Resident #3 was then transferred from the Broda chair back into bed on 07/30/23 at 4:10 A.M. STNA #135 reported the Broda chair had not been used prior to this incident and had not been used since the incident, that she was aware of. STNA #135 verified Resident #3 had her own wheelchair but was unable to say why the Broda chair was used instead of Resident #3's personal wheelchair. Review of the facility policy titled, Dementia Care, dated September 2021 revealed the facility was committed to providing the highest quality of life to their residents diagnosed with dementia and present with dementia and dementia related behaviors while preserving their dignity and self-respect. The physician would order appropriate medications and other interventions to manage behavioral and psychiatric symptoms based on pertinent clinical guidelines and regulatory expectations. Review of the facility policy titled, Emergency Use of Restraints, dated September 2021 revealed physical restraints would be used on an emergency only bases to prevent harm to a resident or others. Physical restraints may be used based on professional judgement to prevent harm to a resident or others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 4 of 6 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 09/06/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview, and policy review, the facility failed ensure the medication error rate was less than five percent as evidenced by two medication errors out of 28 opportunities observed, resulting in a 7.14 percent (%) medication error rate. This affected one (Resident #7) of three residents observed for medication administration. The census was 80. Residents Affected - Few Findings include: Medical record review for Resident #7 revealed an admission date of 09/10/22 with a diagnosis of high blood pressure. Review of Resident #7's most current physician orders for September 2023 revealed carvedilol 3.125 Milligrams (mg) used for high blood pressure and cetirizine 5 mg used for allergies. Observation on 09/05/23 at 7:52 A.M. of Licensed Practical Nurse (LPN) #162 providing medication administration to Resident #7 revealed LPN #162 pulled and administered carvedilol 6.25 mg and cetirizine 10 mg (double doses of both medications). Interview on 09/05/23 at 12:27 P.M. with LPN #162 verified Resident #7 was ordered carvedilol 3.125 mg and LPN #162 administered carvedilol 6.25 mg, and Resident #7 was ordered cetirizine 5 mg and LPN #162 administered cetirizine 10 mg. Review of facility policy titled, Administering Medications, undated, revealed medications shall be administered in a safe and timely manner and as prescribed. The individual administering the medication must check the label to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Number OH00145639. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 5 of 6 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 09/06/2023 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 Based on observation, record review, staff interview, and policy review, the facility failed ensure residents were free from significant medication errors. This affected one (Resident #7) of three residents observed for medication administration. The census was 80. Residents Affected - Few Findings include: Medical record review for Resident #7 revealed an admission date of 09/10/22 with a diagnosis of high blood pressure. Review of Resident #7's most current physician orders for September 2023 revealed carvedilol (heart medication) 3.125 Milligrams (mg) used for high blood pressure. Observation on 09/05/23 at 7:52 A.M. of Licensed Practical Nurse (LPN) #162 providing medication administration to Resident #7 revealed LPN #162 pulled and administered carvedilol 6.25 mg (double the amount ordered). Interview on 09/05/23 at 12:27 P.M. with LPN #162 verified Resident #7 was ordered carvedilol 3.125 mg and LPN #162 administered carvedilol 6.25 mg. Review of facility policy titled, Administering Medications, undated, revealed medications shall be administered in a safe and timely manner and as prescribed. The individual administering the medication must check the label to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Number OH00145639. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 6 of 6