Health inspection·February 8, 2024

F 0641 Ensure each resident receives an accurate assessment. 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, observations, policy review, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments. This affected four (#14, #23, #62 and #241) of twenty-one residents reviewed for assessments. The facility census was 84. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #241 revealed an admission date of 01/18/24, diagnoses included: chronic obstructive pulmonary disease, asthma, oropharyngeal dysphagia, neurocognitive disorder with Lewy bodies, dementia, hypertension, atrial fibrillation, depression, and COVID-19 upon admission. Review of the physician order dated 01/19/24 and timed 1:54 P.M., revealed Resident #241 was ordered a regular diet, pureed with nectar thickened liquids. Review of the care plan dated 01/19/24 identified Resident #241 had an activities of daily living self-care deficit, interventions included one person assist for eating. Resident #241 was also identified as having a dental problem related to missing teeth with interventions in place for staff to provide assistance as needed with oral hygiene, provide medications and treatments as ordered and refer to dental services as needed. Resident #241 was also care planned for an altered nutritional status with chewing and swallowing difficulty with a diagnosis of dysphagia requiring an altered texture diet, interventions included to monitor percentage of intake and changes in eating habits, provide meals, snacks and fluids based on resident food preferences and physician orders and physical therapy and speech therapy evaluations and treatments as needed. Review of the MDS Item set Assessment by patient, dated 01/22/24, completed by Speech Therapist #350 revealed Resident #241 did have difficulty or pain with swallowing and coughed and choked with meals and medications and required a mechanical altered. Review of the admission MDS assessment, dated 01/24/24, revealed Resident #241 had cognitive impairment, required partial assistance for eating and was identified as not having a swallowing disorder or any dental issues. Interview on 02/08/24 at 11:40 A.M. with the MDS Coordinator #318, verified Resident #241's MDS completed on 01/24/24 was inaccurate and did not correctly reflect Resident #241's difficulty with swallowing. Interview on 02/08/24 at 11:47 A.M., with Dietician #351 verified the resident was admitted with orders for pureed meals and nectar thickened liquids, and further verified the assessment completed on 01/22/24 by Speech Therapist #350 revealed the resident was identified as having difficulty with swallowing and was on a mechanical altered diet. Dietician #351 verified the MDS completed on 01/24/24 was inaccurate as it revealed Resident #241 had no issues with swallowing. Dietician #351 also verified; she had signed the MDS on 01/25/24. 2. Review of the medical record for Resident #14 revealed an admission date of 02/19/17, diagnoses included: multiple sclerosis, quadriplegia, major depressive disorder, foot drop, obstructive and reflux uropathy, protein-calorie malnutrition, end stage renal disease, hypertension, anxiety disorder and contracture's of the left upper arm, left knee, left ankle and right ankle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 2 of 20 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 02/08/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of the annual MDS dated [DATE] revealed Resident #14 was cognitively intact, had no functional limitation in range of motion of either the upper or lower extremities and used a wheelchair. Review of the quarterly MDS dated [DATE] revealed Resident #14 had functional limitations in range of motion with impairment on both sides of the upper extremity and both sides of the lower extremity. Residents Affected - Some Review of the care plan for Resident #14 dated 04/26/22 revealed impaired musculoskeletal status related to contractures. Interview on 02/08/24 at approximately 11:40 A.M., with the MDS Coordinator #318, verified the annual MDS 11/09/23 for Resident #14 was inaccurate and stated Resident #14 had no range of motion limitations. 3. Review of Resident #23's medical record revealed an admission date of 06/30/23, with diagnoses of congestive heart failure, hemiplegia and hemiparesis, and atrial fibrillation. Review of a physician's order dated 08/25/23 revealed an order for oxygen two liters received via nasal cannula every shift. The order was indefinite. Review of the quarterly MDS dated [DATE] revealed the resident did not require oxygen therapy. Review of Resident #23's most recent care plan revealed the resident had impaired cardiovascular status related to angina/chest pain, atrial fibrillation, heart failure, hyperlipidemia, hypocholesterolemia, and hypertension. Interventions were to provide oxygen when needed when the resident exhibited signs/symptoms of difficulty breathing such as shortness of breath, cyanosis, and low oxygen saturation. Review of a physician's order dated 01/24/24 to change oxygen tubing and set up every Wednesday on day shift. This order was indefinite. Observation of Resident #23 on 02/06/23 through 02/08/23, revealed the resident required oxygen therapy at all times via an oxygen concentrator. Interview on 02/07/24 at 4:28 P.M., with MDS Coordinator #318 verified the Resident #23's quarterly MDS dated [DATE] was inaccurate. 4. Review of the medical record for Resident #62 revealed an admission date of 09/29/22, with diagnoses of type 2 diabetes and dementia. Review of the eye doctor progress note dated 11/27/23 revealed Resident #62 required glasses for distance and reading. New glasses were ordered. Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 did not use corrective lenses. Observation on 02/05/24 at 3:29 P.M., revealed Resident #62 wearing glasses. Observation on 02/06/24 at 3:52 P.M., revealed Resident #62's son cleaning Resident #62's glasses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 3 of 20 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 02/08/2024 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 0641 and returning them to Resident #62 who put on his glasses. Level of Harm - Minimal harm or potential for actual harm Interview on 02/07/24 at 4:35 P.M., with MDS Coordinator #318 verified the quarterly MDS assessment dated [DATE] was completed inaccurately regarding Resident #62's need for glasses. Residents Affected - Some Review of the policy titled, MDS Completion and Submission Timeframe's, dated September 2021, stated the Assessment Coordinator is responsible for ensuring that resident assessments are submitted in accordance with current federal and state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 4 of 20 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 02/08/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to update resident care plans in a timely manner to reflect the resident's current needs. This affected two (#14 and #44) of 21 residents reviewed for accuracy of the care plan. This had the ability to affect all residents. The facility census was 84. Findings included: 1. Review of Resident #44's medical record revealed an admission date of 08/22/23. Diagnoses included Alzheimer's, diabetes mellitus, chronic kidney disease, sciatica, and transient ischemia accident (TIA). Review of Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no broken or loose-fitting teeth. Review of Resident #44's most recent care plan revealed she was at risk for a dental problem related to age. The plan was silent to being edematous and only having top dentures. Review of Resident #44's dietary notes dated 08/22/23 through 02/01/24 the dietician failed to refer to the fact that the resident was edematous. Interview on 02/06/24 at 2:43 P.M., with Resident #44 revealed she was edematous, but did wear upper dentures. The resident did not own bottom dentures. Interview on 02/07/24 at 4:28 P.M., with MDS Coordinator #331 verified that Resident #44's care plan was inaccurate and failed to address her dental issues. 2. Review of the medical record for Resident #62 revealed an admission date of 09/29/22, with diagnoses of right femur fracture (10/09/23) and left femur fracture (11/08/23). Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 had impaired cognition and ambulated with a wheelchair. Resident #62 required substantial/maximal assistance when transferring from sitting to standing and from the chair to bed and to the toilet. Ambulation was not attempted due to medical condition or safety concerns. Review of the current care plan for Resident #62 revealed the resident had an activities of daily life (ADL) self-care performance deficit due to a right femur fracture. Interventions included two-person assistance for transfers and toileting. Review of the physical therapy progress report dated 01/10/24 revealed Resident #62 required partial/moderate assistance for sitting to standing. Observation on 02/07/24 at approximately 8:15 A.M., revealed Resident #62 in the dining room. Resident #62 stated he needed to use the restroom. Continued observation revealed State Tested Nurse Aide (STNA) #298 assisting Resident #62 into his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 5 of 20 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 02/08/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/07/24 at 8:31 A.M, with STNA #298 revealed Resident #62 required only one person assistance for transfers and toileting since he had recovered from his fractures. Interview on 02/08/24 at 7:53 A.M., with Physical Therapist (PT) #354 revealed Resident #62 received physical therapy since 12/31/23. PT #354 stated on 01/10/24, Resident #62 improved and required partial/moderate assistance for sitting to standing transfers. PT #354 stated Resident #62 only required one person to assist for transfers and toileting since 01/10/24. Interview on 02/08/24 at 1:33 P.M., with MDS Coordinator #318 confirmed Resident #62's ADL care plan was not updated to reflect his need for assistance of only one person for transfers and toileting. MDS Coordinator #318 stated she was not aware of the change to Resident #62's assistance needs and therefore did not update the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 6 of 20 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 02/08/2024 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 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, record review, review of fall investigations, staff interview, and review of policy, the facility failed to facility failed to complete a thorough root cause analysis into why a resident continued to fall. In addition, the facility failed to implement effective fall interventions to prevent falls. This affected two (#62 and #65) of three residents reviewed for falls. The facility census was 84. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 09/29/22 with diagnoses of Alzheimer's, dementia, hypertension, right femur fracture (10/09/23) and left femur fracture (11/08/23). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #62 had impaired cognition and ambulated with a wheelchair. Resident #62 required substantial/maximal assistance when transferring from sitting to standing and from the chair to bed and to the toilet. Ambulation was not attempted due to medical condition or safety concerns. Resident #62 had two or more falls since the previous assessment. Review of the current care plan on 02/07/24 revealed Resident #62 was at risk for falls due to Alzheimer's, dementia, and hypertension. Interventions included non-skid strips in front of the toilet, non-skid strips next to the bed, a raised toilet seat, anti-rollback bars to the wheelchair, and a dump wheelchair (a wheelchair with a seat positioned so the rear of the seat is lower to the ground than the front). Review of the facility's incident log revealed Resident #62 fell on [DATE], 11/06/23, 11/21/23, and 12/25/23. Review of the facility's fall investigations revealed Resident #62 was found in the bathroom after he fell on [DATE] at 1:15 A.M. The root cause was identified as ambulating without assistance. The facility added non-skid strips to the bathroom floor. Review of the fall investigation dated 11/06/23 at 4:15 A.M. revealed Resident #62 was found on the floor of his bedroom when attempting to take himself to the bathroom. The facility implemented non-skid strips next to the bed. Review of the fall investigation dated 11/21/23 at 4:50 P.M. revealed Resident #62 was found in the bathroom. The facility implemented anti-rollback bars to Resident #62's wheelchair. Review of the fall investigation dated 12/25/23 at 12:15 A.M. revealed Resident #62 was found on the floor next to his bed, leaning on his wheelchair. Resident #62 stated he was attempting to use the bathroom. The facility implemented a dump wheelchair. Interview on 02/07/24 at 10:29 A.M., with Regional Support Staff (RSS) #349 revealed he attended morning meetings at the facility for approximately the previous two months. RSS #349 stated the interdisciplinary team (IDT) reviewed falls during the morning meetings. RSS #349 stated the root cause of the falls for Resident #62 was ambulating without assistance and interventions were developed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 7 of 20 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 02/08/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few address the physical situation Resident #62 was in at the time of the fall. RSS #349 stated Resident #62 was walking, or attempting to walk, at the time of the fall, and the IDT implemented interventions to increase walking safety. Continued interview with RSS #349 revealed the IDT did not recognize in each of Resident #62's falls he was attempting to use the restroom. RSS #349 confirmed a dump chair addressed positioning and did not address Resident #62's need or desire to use the bathroom safely. RSS #349 further stated, after recognizing a trend in falls related to bathroom use, an intervention of assisting to the toilet in the middle of the night may have been a more relevant intervention. Observation on 02/07/24 at 8:40 A.M. revealed Resident #62's toilet did not have a raised seat. Interview on 02/07/24 at 8:41 A.M., with Licensed Practical Nurse (LPN) #325 revealed no residents on the secured unit, where Resident #62 was located, had raised toilet seats. Continued interview on 02/07/24 at 8:41 A.M., with LPN #325 and concurrent observation of Resident #62 in the dining room confirmed Resident #62 was in a standard wheelchair, not a dump wheelchair. Interview on 02/08/24 at 1:37 P.M., with RSS #349 confirmed Resident #62 did not have a raised toilet seat until RSS #349 directed staff to provide one after our previous conversation on 02/07/24. Further interview confirmed the intervention for a dump wheelchair for Resident #62 was removed from his care plan. 2. Review of the medical record for Resident #65 revealed an admission date of 01/25/23, with diagnoses including: chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, hypothyroidism, and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 was cognitively intact and required moderate assistance for showers, upper body and lower body dressing, and mobility, used a wheelchair and walker, was incontinent of bowel and bladder and had one fall with no injury during assessment period. Review of the care plan dated 01/26/23 revealed Resident #65 had impaired muscle skeletal status related to arthritis. Interventions included for pain medications to be administered as ordered, encourage resident to ask for assistance, keep call light within reach, monitor for fatigue, encourage resident to take time with activities, treatments as ordered, provide assistance with turning and repositioning as needed and physical therapy and occupational therapy as needed. Review of Resident #65's fall history revealed falls had occurred on 01/26/23, 02/07/23 02/09/23, 02/24/23, 05/12/23, 07/26/23, 09/14/23, 12/12/23 and 12/28/23. Review of the interdisciplinary team review on 09/15/23 of the fall that occurred on 09/14/23 at 11:00 A.M. revealed Resident #65 became dizzy and lightheaded when getting out of the chair. A new intervention was put into place to use extended oxygen tubing so when ambulating to the bathroom Resident #65 did not have to go without required oxygen. Review of the interdisciplinary team review dated 12/12/23 of the fall that occurred on 12/12/23 at 6:00 A.M. when Resident #65 was found sitting on the floor after the resident slid out of bed revealed nonskid strips at bedside and on the bathroom floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 8 of 20 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 02/08/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the interdisciplinary team review dated 12/18/23 of the fall that occurred on 12/17/23 at 1:34 P.M. revealed Resident #65 was trying to sit on the toilet and was unable to move foot revealed the following fall interventions were in place: Educate resident and family to call for assistance before transferring; Education resident not to stand without assistance; Extended oxygen tubing; Food/fluids within reach; Maintain call light within reach; Nonskid strips; Nonskid strips in the bathroom; Nonskid footwear; Reacher; Resident education on safety interventions; and a Toilet riser. Observations on 02/06/24 at 10:48 A.M., 4:38 P.M. and on 12/07/24 at 8:40 A.M., revealed Resident #65 did not have extension tubing, nonskid strips were not in place at bedside or in bathroom and no toilet riser was present. Observation on 02/07/24 at 10:50 A.M., of State Tested Nursing Assistant (STNA) #302 assisting Resident #65 to the bathroom revealed the nasal cannula was removed from Resident #65 prior to the resident being assisted to the bathroom. Interview with STNA #302 at the time of the observation revealed the oxygen tubing is not long enough for Resident #65 to keep on when in the bathroom. Additional interview with STNA #302 at 11:00 A.M., verified Resident #65 did not have nonskid strips on the floor of the bathroom or next to the bed and further verified no toilet riser was in place. Interview on 02/07/24 at 11:05 A.M., with Regional Support #349 confirmed the interventions identified by the multidisciplinary team upon the fall reviews for Resident #65 had not been implemented and further verified the care plan for Resident #65 had not been updated to the reflect the identified interventions. Review of the undated policy titled Falls, stated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Appropriate interventions will be identified to reduce the risk of falls. Interventions, if successful in preventing falls the interventions will continue and if unsuccessful and the resident continues to fall the staff will re-evaluate the situation and determine whether interventions are appropriate to continue or if current interventions need to be changed. Review of the policy titled, Care Plans, Comprehensive Person-Center, dated September 2021, stated a comprehensive, person-centered care plan that includes measurable objectives and timetables to the resident's physical, psychosocial and functional needs is developed and implemented for each resident with ongoing assessment and care plan revisions as information about the resident and the resident condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 9 of 20 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 02/08/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #29's medical record revealed an admission date of 02/18/21. Diagnosis included pneumonia, hypoxemia, and chronic obstructive pulmonary disease. Residents Affected - Few Review of Resident #29's medical record revealed physician orders dated 02/04/24 for oxygen two liters via nasal cannula as needed for shortness of breath. Observation of Resident #29 on 02/05/24 at 10:30 A.M., revealed the resident was receiving oxygen via nasal cannula. The oxygen tubing failed to be dated. Interview on 02/05/24 at 10:33 A.M.,with Licensed Practical Nurse (LPN) #331 verified the resident's oxygen tubing had failed to be dated to ensure staff changed the tubing as required. 3. Review of Resident #23's medical record revealed an admission date of 06/30/23. Diagnosis included congestive heart failure, hemiplegia and hemiparesis, and atrial fibrillation. Review of the MDS dated [DATE] revealed the resident did not require oxygen therapy. Review of Resident #23's most recent care plan revealed the resident had impaired cardiovascular status related to angina/chest pain, atrial fibrillation, heart failure, hyperlipidemia, hypocholesterolemia, and hypertension. Interventions were to provide oxygen when needed when the resident exhibits signs/symptoms of difficulty breathing such as shortness of breath, cyanosis, and low oxygen saturation. Review of Resident #23's medical record revealed a physician's order dated 08/25/23 for oxygen two liters received via nasal cannula every shift. The order was indefinite. Review of Resident #23's medical record revealed a physician's order dated 01/24/24 to change oxygen tubing and set up every Wednesday on day shift. This order was indefinite. Observation on 02/05/24 at 10:43 A.M., revealed Resident #23 was receiving oxygen therapy via nasal cannula and concentrator. The oxygen tubing was dated 01/16/24. Interview on 02/05/24 at 10:45 A.M., with LPN #331 verified Resident #23's oxygen tubing was dated 01/16/24 and the tubing was failed to be changed on 01/23/24 and 01/30/24. Review of the policy titled Oxygen Administered, dated September 2021, stated oxygen therapy is administered by the way of an oxygen mask, nasal cannula and/or nasal catheter. Precautions and or possible complications could include bacterial contamination associated with certain nebulizer and humidifiers may occur. Based on observation, staff interview, record review and review of policy the facility failed to provide appropriate care and services for oxygen therapy. This affected three residents (#23, #29 and #65) of three residents reviewed for oxygen therapy. The facility census was 84. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 10 of 20 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 02/08/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Review of the medical record for Resident #65 revealed an admission date of 01/25/23, diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, hypothyroidism, and schizoaffective disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #65 was cognitively intact and required the use of oxygen therapy. Review of the care plan dated 01/26/23 revealed Resident #65 had an impaired respiratory status related to tobacco use and oxygen use. Interventions included administration of medications as ordered, assistance with activities of daily living as needed to reduce anxiety and respiratory fatigue, for resident to notify staff if having difficulty with breathing, use incentive spirometer as ordered, monitor vital signs and pulse oximetry as needed and oxygen therapy to be administered as ordered. Review of the current physician orders for Resident #65 revealed orders for oxygen therapy at five liters per minute per nasal cannula, oxygen equipment, tubing and set up are to be changed every day shift every Wednesday, pulse oximetry every shift and as needed and elevate head of bed as tolerated. Observation on 02/05/24 at 9:47 A.M., revealed Resident #65 had oxygen infusing at four liters per minute per nasal cannula. The nasal cannula was in place and the oxygen tubing was dated 01/31/24 the humidification bottle on concentrator was undated, empty, and bulging. A clear bag hanging off the regulator on the concentrator contained a nebulizer and tubing dated 01/04/24. Interview on 02/05/24 at 10:30 A.M., with Regional Support #349 confirmed the aforementioned findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 11 of 20 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 02/08/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff schedule review, staff interview, review of the facility assessment the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 84 residents currently residing in the facility. The facility census was 84. Findings include: Review of the nursing staff information and staff schedule from 01/29/24 to 02/04/24 revealed no registered nurses (RN) were present working in the facility on 02/03/24 and 02/04/24. Review of the Facility assessment dated [DATE] stated staffing and staff assignments are determined by the Nursing Administration and Administrative leadership utilizing various reports to analyze the number of patients, velocity of expected admissions and discharges, diagnosis, the total number and type of tasks and services required of nursing, nursing assistants, and other ancillary personnel. Staff assignments are driven by the burden of care, patient location, and acuity. Additionally, staffing is reviewed quarterly and with significant change in facility operation, each position is reviewed to determine that all staff positions required for facility operations have been listed and have appropriate minimum education levels and licensure requirements. All positions, even if the position is currently vacant, are listed including the sufficient number of staff considering the number, acuity, and diagnosis of facility population for continuity of care. Interview on 02/08/24 at 9:35 A.M., with the Administrator verified the facility did not have any RN on duty in the facility on 02/03/24 and 02/04/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 12 of 20 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 02/08/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the policy, the facility failed to ensure blood pressure medications were administered per prescribed parameters. This affected one (#48) of five residents reviewed for medication administration. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 07/28/22 with a diagnosis of hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition. Review of a current physician order dated 08/15/23 revealed Resident #48 was prescribed Lisinopril oral tablet, 10 milligrams (mg) one daily for hypertension. The medication should be held for a blood pressure (BP) less than 130. Review of the November 2023 Medication Administration Record (MAR) revealed Resident #48's blood pressure was documented at the time of the Lisinopril dose. Review of the MAR dated November 2023 revealed Resident #48's received Lisinopril ten times when his BP was below 130: on 11/01/23 (BP 126/87), 11/02/23 (BP 121/98), on 11/11/23 (BP 127/84), on 11/13/23 (BP 129/67), on 11/14/23 (BP 127/62), on 11/21/23 (BP 123/64), on 11/22/23 (BP 124/65), on 11/23/23 (BP 128/64), on 11/26/23 (BP 124/83), and on 11/28/23 (BP 126/72). Review of the December 2023 MAR for Resident #48 revealed he received Lisinopril six times when his BP was below 130: on 12/01/23 (BP 128/77), on 12/02/23 (BP 120/88), on 12/03/23 (BP 120/84), on 12/04/23 (BP 124/74), on 12/07/23 (BP 126/67), and on 12/16/23 (BP 124/62). Review of the January 2024 MAR for Resident #48 revealed he received Lisinopril twice when his BP was below 130: on 01/15/24 (BP 124/68) and on 01/24/24 (BP 128/70). Interview on 02/08/24 at 2:55 P.M., with Regional Support Staff (RSS) #349 confirmed Resident #48's MARs for November 2023, December 2023, and January 2024 revealed Resident #48 received Lisinopril when his BP was less than 130. RSS #349 confirmed the Lisinopril dose should not have been given ten times in November 2023, six times in December 2023 and twice in January 2024. Review of the undated policy titled, Administering Medications, revealed medications shall be administered as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 13 of 20 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 02/08/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of policy, the facility failed to ensure gradual dose reductions were attempted for the use of psychotropic medications. This affected one (#54) of five residents reviewed for psychotropic medications. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admission date of 03/28/22, diagnoses included hemiplegia and hemiparesis following cerebral infarct affecting non dominant left side, mood affective disorder, major depressive disorder, anxiety disorder, suicidal ideation, visual hallucinations, nicotine dependence, and a history of cocaine dependence. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 was cognitively intact, exhibited no behavioral symptoms, had a psychiatric/mood disorders that included anxiety and depression, and was taking an antidepressant and had no gradual reduction attempted. Review of the care plan dated 03/29/22 revealed Resident #54 had impaired psychiatric/mood status related to loss of autonomy, poor self-esteem, and depression. Interventions included for medications and treatments to be administered as ordered, behavioral health consultants as needed, monitoring of acute psychosis or changes from baseline, hallucinations, delusions paranoia, anxiety, suicidal thoughts, and for those changes to be reported to the physician and to monitor signs of mood changes or distress. Review of the February 2023 monthly physician orders for Resident #54 revealed an order for diazepam 2 milligrams (mg) was ordered on 05/12/23 to be administered by mouth three times a day for anxiety; duloxetine hydrochloride delayed release particles 60 mg one capsule once a day for depression ordered on 04/16/23; trazadone 100 mg ordered on 04/15/23 for two tablets by mouth at bedtime and for psychotropic medication behavior monitoring and side effect monitoring each shift. Review of the medication administration records from June 2023 to January 2024 for Resident #54 revealed no documented behaviors. Review of the monthly pharmacy reviews from April 2023 through December 2023 revealed no recommendations for a gradual dose reduction was suggested nor was a gradual dose reduction attempted. Interview on 02/08/24 at 8:30 A.M., with Regional Support #349 verified the medical record for Resident #54 revealed no behaviors. Regional Support #349 also verified monthly pharmacy reviews had been completed with no recommendation of gradual dose reductions and further verified Resident #54 has not had any attempts to reduce the dosages of the prescribed antipsychotic medications prescribed. Review of the policy titled Psychotropic's, dated September 2021, stated the facility will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications. Additionally, the policy stated residents who sue psychotropic drugs will receive gradual dose reductions and behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 14 of 20 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 02/08/2024 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 0758 interventions, unless clinically contraindicated. 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: 365745 If continuation sheet Page 15 of 20 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 02/08/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **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 food was prepared and appropriate to meet resident's needs and according to their assessment, physician order, and care plan. This affected two (#45 and #241) of two residents reviewed for nutrition and hydration. The facility census was 84. Findings include: 1. Review of the medical record for Resident #241 revealed an admission date of 01/18/24, diagnoses included chronic obstructive pulmonary disease, asthma, oropharyngeal dysphagia, neurocognitive disorder with Lewy bodies, dementia, hypertension, atrial fibrillation, and depression. Resident #241 also had COVID-19 upon admission. Review of the care plan dated 01/19/24 identified Resident #241 had an activities of daily living self-care deficit, interventions included one person assist for eating. Resident #241 was also identified as having a dental problem related to missing teeth with interventions in place for staff to provide assistance as needed with oral hygiene, provide medications and treatments as ordered and refer to dental services as needed. Resident #241 was also care planned for an altered nutritional status with chewing and swallowing difficulty with a diagnosis of dysphagia requiring an altered texture diet, interventions included to monitor percentage of intake and changes in eating habits, provide meals, snacks and fluids based on resident food preferences and physician orders and physical therapy and speech therapy evaluations and treatments as needed. Review of the physician order dated 01/19/24 and timed 1:54 P.M. revealed Resident #241 was ordered a regular diet, pureed with nectar thickened liquids. Review of the Minimum Data Set (MDS) Item Set Assessment by Patient dated 01/22/24 completed by Speech Therapist #350 revealed Resident #241 did have difficulty or pain with swallowing and coughed and choked with meals and medications and required a mechanical altered. Review of the admission MDS dated [DATE] revealed Resident #241 had cognitive impairment, required partial assistance for eating and was identified as not having a swallowing disorder or any dental issues. Continuous observation on 02/05/24 from 12:20 P.M. to 12:40 P.M., of the lunch meal revealed Resident #241 coughed after taking a drink of the liquids, juice, and coffee, served will the lunch meal. At 12:40 P.M., Speech Therapist (ST) #350 walked into the dining room and directly to the table were Resident #241 was sitting. ST #350 inquired who served Resident #241 and further stated Resident #241's liquids were not thickened. ST #350 removed the liquids, added thickener, and returned the liquids from Resident #241. Interview on 02/07/24 at 10:18 A.M. with Speech Therapist #350, verified Resident #241 did not have nectar thickened liquids on Monday, 02/05/24 with the lunch meal and was coughing and choking with each drink of the liquids the resident took. Speech Therapist #350 verified Resident #241 has had an order for nectar thickened liquids since admission and further verified the meal ticket for Resident #241 did state the resident required nectar thickened liquids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 16 of 20 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 02/08/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #45 revealed an admission date of 06/30/23, with diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). Review of the quarterly MDS assessment dated [DATE] revealed Resident #45 had impaired cognition. Resident #45 demonstrated no difficulty swallowing. Residents Affected - Few Review of the physician order dated 02/02/24 revealed Resident #45 should receive a regular diet with mechanical soft texture and thin liquids. Observation on 02/05/24 at approximately 11:55 A.M., revealed Resident #45 received a pureed meal. Continued observation revealed Speech Therapist (ST) #350 advising staff Resident #45 should have received a mechanical soft diet. Interview on 02/05/24 at 11:57 A.M., with ST #350 confirmed she changed Resident #45's diet order to mechanical soft last week and turned in a diet slip to the kitchen. Follow up interview on 02/07/24 at 10:25 A.M., with ST #350 confirmed Resident #45's meal ticket at lunch on 02/05/24 showed Resident #45 should receive a pureed diet, which was an error and did not follow the physician's order for a mechanical soft diet. Review of the undated policy titled Telephone Orders, revealed orders must be recorded in the resident's medical record and contain instructions from the physician. This deficiency represents non-compliance investigated under Complaint Number OH00150127. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 17 of 20 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 02/08/2024 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 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. Based on observation, staff interview, review of cleaning list, and review of policy, the facility failed to ensure a clean and sanitary kitchen, ensure all food items were dated when opened and contained used by dates. This had the potential to affect all 84 residents who received food from the kitchen. The facility census was 84. Findings include: Observation during the tour of the kitchen on 02/05/24 between 8:27 A.M. and 9:00 A.M., of the kitchen revealed a buildup of a black substance on around the baseboards of the kitchen, a dirty microwave with a variety of dried color splatter, dried patterns of dried substances on a variety of metal shelving, including a dried white splatter on the cart containing boxes of foil and plastic wraps and an air conditioner in the window next to the grill top with brown/yellow colored debris. Refrigerator with unlabeled and undated bowls (three) of a brown substance, 2 gallons of chocolate milk without open dates, and in the dry storage room revealed an onion on the floor below a wheeled cart that contained a pan of uncovered, undated cornbread. Labeled food items with an open date were absent of use by dates. Interview on 02/05/24, during the tour of the kitchen, with [NAME] #219 verified the used by dates were not on the open food items, the brown substances in three bowls were not labeled, two gallon of chocolate milk contained no open date and further verified the cornbread was uncovered and undated. [NAME] #219 further verified the dirty substance in the microwave, the dried substances on tables and shelves and further verified food items on the floor. Additional interview with Dietary Manager #347 on 02/06/24 at 10:30 A.M., verified corners and baseboards in kitchen with thick coat of black colored substance, the air conditioner in the window ow to the right of the grill top with brown/yellow colored debris on the front grill. Dietary Manager #347 stated they cannot get the floor clean, and the facility is looking to replace the floor and further stated the air conditioner is cleaned regularly when in use, adding this time of year the air conditioner is not used. Review of the undated policy titled Refrigerators and Freezers, stated the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (date of delivery) will be marked on cases and on individual items removed from the cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and used by dates indicated once the food is opened. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Review of the undated, Daily Cleaning List, revealed food carts, stock rooms, microwave and walls and floors are cleaned on a scheduled basis. Review of the Daily Cleaning List was silent for air conditioner cleaning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 18 of 20 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 02/08/2024 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** 2. Review of the facility Legionella Chlorine Testing Log dated 10/05/22 through 02/05/24 revealed chlorine water testing was completed once weekly in various locations throughout the facility. No negative outcomes were identified. Residents Affected - Many Interview on 02/07/24 at 4:10 P.M., with Maintenance Director #289 verified Legionella chlorine testing was completed once every week and he was unaware of the facility policy. Review of the policy titled Legionnaire's Disease Prevention/Treatment Best Practice dated September 2023, revealed maintenance staff will check the chlorine level of the water three to five times weekly at different locations. Based on observation, medical record review, testing log review, staff interview, review of material data sheet for disinfectant, and policy review, the facility failed to maintain appropriate infection control practices when cleaning a resident's room in isolation precautions for Clostridium Difficile (C-Diff) infection; utilize proper hand hygiene; and failed to ensure water monitoring for Legionella was completed. This had the potential to affect all 84 residents. The facility census was 84. Findings include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, morbid obesity, pulmonary hypertension, lymphedema, hypertension, anxiety disorder, depression, insomnia. Resident #16 tested positive for C-diff on 01/27/24. Review of the care plan for Resident #16 revealed the resident had a C-diff infection and required contact isolation precautions with a goal for Resident #16 to have no complications related to the C-diff infection. Review of the current physician orders revealed an order written on 01/27/24 for Resident #16 to be placed in contact isolation precautions, and to administer vancomycin 125 milligrams (mg), one capsule by mouth every six hours for ten days starting 01/29/24 for the treatment of C-diff. Interview on 02/07/24 at 02:18 P.M., with the Director of Environmental Services #297 revealed Neutral Disinfectant Cleaner for all flat surfaces and is used to clean contact isolation rooms including C-diff isolation. Observation on 02/07/24 at 3:01 P.M., revealed Housekeeping Aide #224 don gloves prior to entering Resident #16's room. Housekeeping Aide #224 removed two yellow isolation bags of trash were removed from the room and placed them in the cleaning cart trash bin using gloved hands to open the cleaning cart trash bin sitting outside Resident #16's room. Housekeeping Aide #224, then using gloved hands removed and rag from a bucket on the cleaning cart and a spray bottle of yellow colored solution labeled Neutral Disinfectant Cleaner, sprayed the two black bins for which the yellow trash bags labeled isolation were removed from, sat the spray bottle of disinfectant on the floor and wiped the black bins down using the rag. After wiping down the black bins the rag was placed in bag on the cleaning cart with other used rags and mop heads and the spray bottle of disinfectant was placed on the top of the cleaning cart. Housekeeping Aide #224 removed one yellow and one red bag, both labeled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 19 of 20 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 02/08/2024 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 isolation, from the cleaning cart using the same gloved hands used to clean the black isolation bins and placed a yellow liner in one of the black bins and the red liner in the other. Interview on 02/07/24 at 3:15 P.M., with Housekeeping Aide #224 revealed the Neutral Disinfecting Solution is used to clean all surfaces in all rooms and verified the trash and the materials used to clean the C-diff isolation room were placed in and on the cleaning cart, and verified the rag used to clean the black isolation bins was placed with the soiled rag bag with the other rags used throughout the day. Interview on 02/07/24 at 4:43 P.M., with the Director of Environmental Services #297 verified the mop heads and rags go into a bag after each room is cleaned and the bag when full is taken to laundry, the cleaning materials when cleaning a C-diff room are not isolated or separated. Additionally, the Director of Environmental Services #297 verified after reviewing the Neutral Disinfecting Solution directions for use and after checking with the vendor of the product the Neutral Disinfectant Cleaner does not kill C-diff spores and was the improper disinfectant for cleaning residents room in isolation for C-diff. Review of the undated material sheet for Neutral Disinfectant Cleaner instructions for use did not identify as being effective against C-diff. Observation of meal service on 02/08/24 at 8:43 A.M., for Resident #16 was completed. State Tested Nursing Aide (STNA) #282 was observed taking Resident #16's tray into her room which was under infection control precautions due to a diagnosis of C-diff. The STNA moved items around on the resident's bedside table with her bare hands and placed the meal tray onto the table. STNA #282 then exited the room, shut the door, and proceeded to take the next resident's tray off of the meal cart. STNA #282 failed to wash her hands with soap and water nor use hand sanitizer. Interview on 02/08/24 at 8:44 A.M., with STNA #282 revealed she failed to wash her hands after leaving Resident #16's room and proceeded to touch other resident meal trays. STNA #282 stated staff was not required to do so in the past. Review of the undated facility policy titled Infection Preventions and Control Program, stated the infection prevention and control program are a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Additionally, important facets of infection prevention include identifying possible infections or potential complications of existing infections, education of staff to ensure adherence to proper techniques and procedures. the facility must also establish policies and procedures regarding infection control including implementation of precautions to prevent individuals from contracting infections and the proper use of personal protective equipment, including checks for its proper use and appropriate means of disposal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365745 If continuation sheet Page 20 of 20