Inspection·April 11, 2022

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview, and policy review, the facility failed to ensure one resident (#44) of one reviewed for hospitalization received a transfer notice upon transfer. The facility census was 47. Findings include: Review of the closed medical record of Resident #44 revealed an admission date of 10/13/21 and a discharge date of 01/09/22 to the hospital. Diagnoses included myocardial infarction, type II diabetes mellitus, cardiac arrhythmia's, cardiomyopathy, and congestive heart failure. Review of the progress notes revealed Resident #44 was sent to the hospital on [DATE] with complaints of abdominal pain. The note included her husband had been notified of the transfer. Review of the record revealed no evidence a transfer notice upon transfer had been given to the resident or her family representative. Interview on 04/07/22 at 2:30 P.M., with the Administrator and the Director of Nursing provided verification the closed medical record did not contain the Transfer Notice. Review of the facility policy titled Transfer and Discharge dated 12/01/18 revealed at the time of transfer (or as soon as practicable) for hospitalization, the facility will provide the resident or representative written notice which documents: resident status; current diagnosis, allergies and reason for transfer/discharge; contact information of the practitioner responsible for the care of resident; current medications and treatments; any special risks or precautions; and any other applicable documents necessary to ensure a safe and effective transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 2 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure resident care plans were developed with measurable objectives, timelines or interventions. This affected one resident (#19) of 14 reviewed for care planning. The facility census was 47. Findings include: Review of medical record for Resident #19 revealed an admission date of 02//1/18. Diagnoses included cerebral palsy, contracture of right and left knee, depression, anxiety, hypertension and reflux. The quarterly minimum data set (MDS) dated [DATE] revealed Resident#19 had intact cognition and was an extensive two person assist for bed mobility, dressing and personal hygiene. Resident #19 was dependent for transfers, toilet use and supervision for eating. Section M of the MDS revealed a pressure ulcer /injury and an unhealed pressure ulcer marked as a stage three ulcer not present upon admission. The use of pressure reducing device for the bed and pressure ulcer care was documented during the assessment. Review of the care plan for potential for skin integrity was initiated on 12/03/21 with interventions to encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible. There was no care plan for the documented pressure ulcer for Resident#19. Interview on 04/07/22 at 11:42 A.M., with the MDS Registered Nurse #100 verified there was no care plan addressing the stage three pressure ulcer of Resident#19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 3 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 and staff interviews the facility failed to implement new safety interventions following a fall experienced by two residents (#17 and #95) of five residents (#02, #07, #17, #32, and #95) reviewed for falls. The facility census was 47. Findings include: 1. Review of the medical record of Resident #17 revealed an admission date of 08/18/21. Diagnoses included congestive heart failure, history of falling, difficulty in walking, cognitive communication deficit, and dementia without behavioral disturbance. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #17 had severe cognition deficit and required supervision with walking in room and transfers. She was assessed as having no impairment with upper or lower extremity range of motion and used no mobility aids. The assessment revealed she had experienced one fall, without injury, since admission. Review of the care plan with a revised date of 03/31/22 revealed Resident #17 was at a risk for falls related to dementia, anxiety, weakness, depression, hypoxemia, and atrial fibrillation. No new interventions were initiated after the fall experienced on 02/23/22. Review of the progress note dated 02/23/22 at 7:00 P.M. revealed Resident #17's call light had activated. Upon entering the room she was found on the floor. Her roommate stated she had been walking over to a recliner, stumbled and fell. Resident #17 was noted to have shoes on both feet and no debris was noted on the floor. 2. Review of the medical record of Resident #95 revealed an admission date of 02/17/22. Diagnoses included paroxysmal atrial fibrillation, cognitive communication deficit, metabolic encephalopathy, type II diabetes mellitus, end stage renal disease and dependence on renal dialysis. Review of the discharge-return modification of admission minimum data set (MDS) assessment dated [DATE] revealed Resident #95 had moderate cognition deficit. Review of the progress notes revealed an entry on 03/18/22 at 10:45 P.M. revealed Resident #95 had fallen from her bed and had sustained a fracture to the left wrist and the left knee. Review of the care plan for Resident #95 revealed the last update with fall prevention interventions were added on 03/10/22. Interview on 04/07/22 at 11:00 A.M., with Registered Nurse #100 provided verification of the lack of modification to the care plan following Resident #17 and Resident #95's fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 4 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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, observation, staff interview and policy review the facility failed to ensure a pressure wound was assessed. This affected one resident (#19) of three residents reviewed for pressure ulcers. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed admission date of 02//1/18. Diagnoses included cerebral palsy, contracture of right and left knee, depression, anxiety, hypertension and reflux. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident#19 had intact cognition and was an extensive two person assist for bed mobility, dressing and personal hygiene. Resident #19 was dependent for transfers, toilet use and supervision for eating. Review of the Section M of the MDS revealed a pressure ulcer /injury and an unhealed pressure ulcer marked as a stage three ulcer not present upon admission. The use of pressure reducing device for the bed and pressure ulcer care was documented during the assessment. Review of the care plan for potential for skin integrity was initiated on 12/03/21 with interventions to encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible. There was no care plan for the documented pressure ulcer for Resident #19. Review of the skin assessment for Resident#19 dated 02/13/22 revealed documentation of a sacral wound and the description which read reopened which measured 1.0 centimeter (cm) by 0.5 cm by 0.1 cm. Record review of the progress note for Resident #19 dated 02/13/22 revealed the sacral area had reopened. The area was cleansed, the physician was informed, and new orders were received. Review of the physician order for Resident #19 revealed on order dated 02/13/22 to cleanse the sacrum with wound wash or soap and water and pat dry. Apply calcium alginate with silver and cover with a dry dressing daily. Further review of the progress notes and the physician orders for Resident #19 revealed no orders to consult the wound nurse and no documentation the resident had been seen by the wound nurse after 02/01/22. Review of the skin assessment for Resident #19 dated 03/08/22 and 03/16/22 revealed documentation the wound nurse continued treating the sacrum area. No description or measurements of the wound were documented. Review of the skin assessment for Resident #19 dated 03/30/22 revealed no new areas noted. There was an existing area to the sacrum, treatments were in place. Observation and interview on 04/07/22 at 10:32 A.M. during the dressing change for Resident #19 by Licensed Practical Nurse (LPN) #202 revealed she was unsure of the wound measurements and believed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 5 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the wound nurse was measuring the wound. The wound was small in size and there appeared to be a small slit or opening with sanguineous (the first drainage a wound produces, it is fresh red blood that comes out of the injury when it first occurs) drainage observed on the gauze when LPN #202 cleansed the wound. The wound measured 1.0 cm by 0.3 cm and no depth. LPN #202 said the wound had improved. Interview on 04/07/22 at 1:49 P.M., with the Director of Nursing verified the wound nurse had not seen Resident#19 since 02/01/22 and no wound measurements or description of the wound had been documented by the staff since 03/08/22. The treatments were completed just not the weekly measurements and assessments of the sacrum wound. Review of facility policy/protocol titled Wound Treatment Management dated 12/01/18 revealed the effectiveness of treatments would be monitored through the ongoing assessment of the wound. Treatment decisions would be based on the characteristics of the wound including but not limited to the size, presence of infection, condition of the tissue in and around the wound bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 6 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure a urine sample for the laboratory test urinalysis was obtained in a timely manner. This affected one resident (#30) of one resident reviewed for urinary tract infection (UTI). The facility census was 47. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of the bladder, intellectual disabilities, epilepsy, peripheral vascular disease, and hemiplegia. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition. The assessment revealed the resident utilized an indwelling urinary catheter. Review of a progress noted dated 03/29/22 at 5:31 P.M. revealed Resident #30 was noted to be acting different. The residents urine was assessed brown in color. A new order from the nurse practitioner was received to obtain urinalysis. Review of a physician order dated 03/29/22 revealed a urinalysis (a clinical urine test conducted for the examination of urine and its microscopic appearance to aid in medical diagnosis) was ordered for Resident #30. Review of the medical record for Resident #30 revealed the medical record contained no evidence of an attempt to obtain a urine sample for urinalysis on 03/29/22 or 03/30/22. Review of a laboratory test, specimen collection date 03/31/22 revealed a urine sample was collected for Resident #30 on 03/31/22. The abnormal results were reported to the facility on [DATE]. Interview on 04/07/22 at 11:20 A.M., with the Director of Nursing (DON) revealed it was the DON's expectation that a urinalysis, ordered for a resident with an indwelling urinary catheter, would be collected the same day of the urinalysis order unless specified otherwise in the order. The DON verified Resident #30 utilized an indwelling urinary catheter. The DON verified a urinalysis was ordered for Resident #30 on 03/29/22 and the urine sample was not collected until 03/31/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 7 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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** Based on medical record review, observation, staff interview, review of the manufacturers recommendations and policy review the facility failed to ensure one resident (#95) had an order for oxygen administration. The facility failed to ensure documentation of oxygen administration for one resident (#94) and the facility failed to ensure oxygen tubing was labeled and dated for four residents (#31, #36, #94 and #95) of four residents reviewed for oxygen use. The facility census was 47. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #95 revealed an admission date of 02/17/22. Diagnoses included paroxysmal atrial fibrillation, cognitive communication deficit, metabolic encephalopathy, type II diabetes mellitus, end stage renal disease and dependence on renal dialysis. Review of the discharge-return modification admission minimum data set (MDS) assessment dated [DATE] revealed Resident #95 had moderate cognition deficit. The assessment indicated she was administered oxygen. Review of the physician orders revealed an order dated 02/18/22 and discontinued on 03/18/22 for oxygen two liters per minute (LPM) via nasal cannula as needed. Review of the medical record revealed Resident #95's oxygen saturation levels were monitored 61 times and indicated she was receiving oxygen via nasal cannula 46 percent of the assessments. The oxygen saturation levels were recorded as 94 to 98 percent both while resident was receiving supplemental oxygen or not (room air). Review of the skilled assessments revealed her lungs were clear to auscultation and no cough was noted. Observation of Resident #95 on 04/04/22 at 8:30 P.M., on 04/05/22 randomly throughout the day and on 04/06/22 from 1:00 P.M. to 3:30 P.M. revealed her to have oxygen on via nasal cannula at two LPM. Direct observation on 04/04/22 at 8:15 P.M. revealed no date on the oxygen tubing. Interview on 04/04/22 at 10:00 P.M. with State Tested Nursing Assistant (STNA) #301 verified the oxygen tubing was undated on both Residents #94 and #95. Interview on 04/06/22 at 2:20 P.M., with Licensed Practical Nurse #201 verified Resident #95 had oxygen on and had no current order for it. Review of the facility policy titled Oxygen Administration dated 08/01/19 revealed oxygen is administered under orders of a physician. 2. Review of the medical record of Resident #94 revealed an admission date of 03/17/22. Diagnoses included unspecified atrial fibrillation, pneumonia, alcohol abuse, anemia, and chronic obstructive pulmonary disease. Review of the admission MDS assessment dated [DATE] revealed Resident #94 was cognitively intact and was not receiving oxygen. Random observations on 04/04/22 through 04/07/22 revealed Resident #94 had oxygen being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 8 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 administered via nasal cannula at two LPM. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders dated 03/18/22 revealed oxygen via nasal cannula at two LPM to keep oxygen saturation above 90 percent. Residents Affected - Some Review of the medical record revealed 28 documentation's of oxygen saturation ranging from 95 percent to 100 percent on oxygen via nasal cannula recorded 20 times and saturation levels of 95 percent to 98 percent on room air recorded eight times. Review of the skilled evaluations documented 10 times revealed her lungs were clear to auscultation bilaterally and no difficulty breathing or cough was noted. Review of the nurses' progress notes revealed only one entry with mention of the need for oxygen. The entry dated 03/22/22 at 12:03 A.M. revealed resident had complained of inability to breathe. Oxygen saturation was 97 percent. No lung assessment was documented and no indication if resident was on supplemental oxygen at the time. Review of the vital sign documentation revealed on 03/22/22 at 12:49 A.M. she was on supplemental oxygen via nasal cannula. Interview on 04/06/22 at 2:30 P.M., with LPN #201 verified Resident #94 had received oxygen throughout her shift and had no documentation of the oxygen being administered. Review of the facility policy titled Oxygen Administration dated 08/01/19 revealed oxygen is administered under orders of a physician. 3. Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypotension, dysphagia, diarrhea, hypertension, and cognitive deficit. Review of Resident #36's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #36 had impaired cognition and did not require supplemental oxygen. Review of Resident #36's physician orders dated 02/28/22 revealed an order for oxygen infusing at two liters per nasal cannula. Review of the orders dated 03/12/22 revealed the oxygen order was revised to infuse at two to six liters per nasal cannula. Review of Resident #36's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 03/2022 and 04/2022 revealed no order was noted in the records for the use of the supplemental oxygen. Review of Resident #36's care plans dated 02/28/22 and the 03/16/22 revision revealed there was no documentation of a focus for supplemental oxygen therapy in the resident's care plans. Observation on 04/05/22 at 9:15 A.M. revealed Resident #36 was sitting in her room in the recliner. Resident #36 appeared to be pleasantly confused. Resident #36's oxygen nasal cannula was observed to be coiled up laying on the floor next to the resident's recliner and the air concentrator was on. The nasal cannula did not have a dated label noted on the tubing. Interview on 04/05/22 at 9:20 A.M. with STNA #305 verified Resident #36 wore her oxygen nasal cannula continuously. STNA #305 verified there was no dated label on the oxygen tubing and the tubing was laying on the floor during the observation. STNA #305 was observed picking up the nasal cannula off the floor and reapplying to Resident #36's face. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 9 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 - Some Interview on 04/07/22 at 9:50 A.M. with the DON verified there was a physician order for supplemental oxygen dating 02/28/22 and revised on 03/12/22 for Resident #36. The DON verified there was no care plan focus for the oxygen and there was no records of the oxygen on the 03/2022 and 04/2022 MAR and TAR for the resident. Review of the facility policy titled, Oxygen Administration dated 08/01/2019 revealed oxygen is to be administered consistent with professional standards of practice, comprehensive care plans, and with the resident's goals and preferences. Per the policy the resident's care plans shall identify interventions for oxygen therapy based upon the residents' assessments and physician orders. 4. Review of the medical record for Resident #31 revealed an admission date of 03/11/22. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, vascular dementia without behaviors. Review of the admission MDS assessment dated [DATE] revealed Resident #31 needed extensive assistance of one for bed mobility, transfer, dressing, toilet use. Section O of the MDS revealed the resident was on oxygen during the look back period. Review of physician orders revealed orders for oxygen 2 liters nasal cannula, may titrate to keep oxygen saturation above 90 percent. No orders for changing of oxygen tubing were documented. Observation on 04/05/22 at 8:31 A.M. revealed Resident #31's oxygen tubing was not dated. Review of the manufacturers recommendations for oxygen tubing/cannula use revealed the typical life span, if kept clean, a nasal cannula will last about two months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 10 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify the primary care provider (PCP) of urinalysis culture and sensitivity results. This affected one resident (#30) one resident reviewed for urinary tract infection. The census was 47. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of the bladder, intellectual disabilities, epilepsy, peripheral vascular disease, and hemiplegia. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition. The assessment revealed the resident utilized an indwelling urinary catheter. Review of a laboratory test reported 03/13/22 revealed Resident #30 had abnormal urinalysis results. A culture and sensitivity was indicated. The organisms identified were Escherichia coli growth was greater than 100,000 colony forming unit (CFU) per milliliter (ml) and enterococcus faecalis 60-70,000 CFU/ml. Review of the sensitivity report revealed the organism Escherichia coli was resistant to Bactrim (an antibiotic). There was no sensitivity listed for Bactrim related to the enterococcus faecalis. Review of a progress note dated 03/13/22 9:36 P.M. revealed a new order was received for the antibiotic Bactrim DS (double strength) 800 milligram (mg) -160 mg by mouth twice a day for 10 days due to urinary tract infection. Review of a physician order dated 03/14/22 revealed Resident #30 was ordered Bactrim DS Tablet 800-160 mg(Sulfamethoxazole-Trimethoprim), give one tablet orally two times a day for urinary tract infection (UTI). Review of a care plan dated 03/14/22, revealed Resident #30 was on antibiotic therapy (Bactrim DS) related to infection (UTI). Interventions include report pertinent laboratory results to the medical doctor (MD). Review of the medication administration record dated March 2022 revealed Bactrim was administered to Resident #30 as ordered for 10 days. Review of the medical record for Resident #30 revealed there was no evidence of the PCP being notified of the culture and sensitivity results for the urinalysis or of the PCP being notified of the Bactrim resistance. Interview on 04/07/22 at 11:20 A.M., with the Director of Nursing (DON) verified Resident #30 was ordered Bactrim to treat a urinary tract infection (UTI). The DON further verified according to the culture and sensitivity results the UTI was resistant to Bactrim. The DON did not know if the PCP was notified of the culture and sensitivity results. Interview on 04/07/22 at 11:30 A.M., with the Nurse Practitioner (NP) #600 revealed the NP was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 11 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 0773 Level of Harm - Minimal harm or potential for actual harm provider who ordered the antibiotic Bactrim for Resident #30 for the treatment of a UTI. The NP #600 revealed the order for the Bactrim was given prior to the culture and sensitivity results. The NP #600 revealed the facility staff had not notified the NP of the culture and sensitivity results. If the NP #600 would have been made aware of the culture and sensitivity results then the Bactrim would have been discontinued and a different antibiotic would have been ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 12 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review the facility failed to ensure proper infection control protocols in regards to equipment used to provide supplemental oxygen. This affected one resident (#36) out of four residents reviewed for supplemental oxygen use. The facility census was 47. Residents Affected - Few Findings include: Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypotension, dysphagia, diarrhea, hypertension, and cognitive deficit. Review of Resident #36's Minimum Dat Set (MDS) comprehensive assessment dated [DATE] revealed Resident #36 had impaired cognition and did not require supplemental oxygen. Review of Resident #36's physician orders dated 03/12/22 revealed an order for oxygen at two to six liters per nasal cannula. Observation on 04/05/22 at 9:15 A.M., Resident #36 was sitting in her room in the recliner. Resident #36 appeared to be pleasantly confused. Resident #36's oxygen nasal cannula was observed coiled up laying on the floor next to the resident's recliner and the air concentrator was on. The nasal cannula was undated and there was no label noted on the tubing. Interview and observation on 04/05/22 at 9:20 A.M. with State Tested Nursing Assistant (STNA) #305 verified Resident #36 wore her oxygen nasal cannula continuously. STNA #305 verified there was no dated label on the oxygen tubing and the tubing was laying on the floor during the observation. STNA #305 was observed picking up the nasal cannula from the floor and reapplying it to Resident #36's face. Interview on 04/07/22 at 9:50 A.M., with the Director of Nursing (DON) verified if a nasal cannula was observed on the floor the aide should report to the nurse for a new clean cannula. Review of the facility policy titled, Oxygen Administration dated 08/01/2019 revealed oxygen is to be administered consistent with professional standards of practice, comprehensive care plans, and with the resident's goals and preferences. Per the policy re-usable and non-reusable equipment for the supplemental oxygen should be used by the staff per standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 13 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 0881 Implement a program that monitors antibiotic use. 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, review of the infection surveillance documentation and policy review the facility failed to implement antibiotic stewardship protocols to ensure appropriate antibiotic use. This affected one resident (#30) of one resident review for urinary tract infection. The census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of the bladder, intellectual disabilities, epilepsy, peripheral vascular disease, and hemiplegia. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition. The assessment revealed the resident utilized an indwelling urinary catheter. Review of a laboratory test reported 03/13/22 revealed Resident #30 had abnormal urinalysis results. A culture and sensitivity was indicated. The organisms identified were Escherichia coli growth was greater than 100,000 colony forming unit (CFU) per milliliter (ml) and enterococcus faecalis 60-70,000 CFU/ml. Review of the sensitivity report revealed the organism Escherichia coli was resistant to Bactrim. There was no sensitivity listed for Bactrim related to the enterococcus faecalis. Review of a progress note dated 03/13/22 9:36 P.M. revealed a new order was received for the antibiotic Bactrim DS (double strength) 800 milligram (mg) -160 mg by mouth twice a day for 10 days due to urinary tract infection. Review of a physician order dated 03/14/22 revealed Resident #30 was ordered Bactrim DS Tablet 800-160 mg(Sulfamethoxazole-Trimethoprim) give one tablet orally two times a day for urinary tract infection (UTI). Review of a care plan dated 03/14/22, revealed Resident #30 was on antibiotic therapy (Bactrim DS) related to infection (UTI). Interventions include report pertinent lab results to the medical doctor (MD). Review of the medication administration record dated 03/22 revealed Bactrim was administered to Resident #30 as ordered for 10 days. Review of the medical record for Resident #30 revealed there was no evidence of the PCP being notified of the culture and sensitivity results for the urinalysis or of the PCP being notified of the Bactrim resistance. Review of infection surveillance documentation dated 03/13/22 revealed Resident #30 was evaluated for a UTI. The criteria with indwelling catheter was purulent discharge from around the catheter or acute pain and urinary catheter specimen culture with greater than or equal to 100,000 CFU/ml of any organism. Documentation revealed Bactrim DS 800-160 mg one tablet oral for 10 days was ordered. The urinalysis results including culture and sensitivity report date 03/13/22 was attached. The document reported UTI evaluated with criteria met. Interview on 04/07/22 at 11:20 A.M., with the Director of Nursing (DON) verified Resident #30 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 14 of 15 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 365854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Nursing Center 501 West Lexington Road Eaton, OH 45320 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordered Bactrim to treat a urinary tract infection (UTI). The DON further verified, according to the culture and sensitivity results the UTI was resistant to Bactrim. The DON did not know if the PCP was notified of the culture and sensitivity results. Interview on 04/07/22 at 11:30 A.M., with the Nurse Practitioner (NP) #600 was the provider who ordered the antibiotic Bactrim for Resident #30 for treatment of a UTI. The NP #600 revealed the order for the Bactrim was given prior to the culture and sensitivity results. The NP #600 revealed the facility had not notified the NP of the culture and sensitivity results. If notification would have been made of the culture and sensitivity results then the Bactrim would have been discontinued and a different antibiotic would have been ordered. Review of a policy titled, Antibiotic Stewardship Program dated 12/18, revealed it is the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy revealed, whenever possible, narrow spectrum antibiotics that are appropriate for the condition being treated shall be utilized. Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365854 If continuation sheet Page 15 of 15