Health inspection·December 18, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications carts were secure. This affected nine (#20, #27, #44, #57, #61, #79, #82, #87, and #121) residents identified by the facility who were cognitively impaired and independently mobile on the Cedar and Dogwood Units. The facility census was 116. Findings include: Observation on 12/16/19 at 10:49 A.M. revealed the Cedar and Dogwood Unit medications carts were located in the common area outside the nurse station. The Cedar Unit medication cart was located on the left side of the common area at the hallway entrance to Cedar Unit, and the Dogwood medication cart was located on the right side of the common area at the hallway entrance to Dogwood Unit. Both medications carts were observed to be unlocked. Four residents (#54, #55, #112, and #121) were observed sitting in the common area near both carts with no staff members observed within eye sight of the unlocked medication carts. Observation on 12/16/19 at 10:53 A.M. revealed Licensed Practical Nurse (LPN) #340 walking up the Dogwood Unit hallway toward the common area where the unlocked medication carts were located. Interview on 12/16/19 at 10:54 A.M. with LPN #340 stated she was the nurse in charge of both Cedar and Dogwood Unit medications carts and verified both medications carts were unlocked with no staff member supervision. LPN #340 then locked both medication carts after verification. Interview on 12/18/19 at 11:19 A.M. with Assistance Director of Nursing (ADON) #300 verified Residents #20, #27, #44, #57, #61, #79, #82, #87, and #121 were cognitively impaired and independently mobile and resided on the Cedar and Dogwood Units. Review of an undated facility policy titled, Storage and Maintenance of Medication, revealed all medications, except those requiring refrigeration, shall be kept in locked medication carts and cabinets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365973 If continuation sheet Page 2 of 5 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 365973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchaven Retirement Village 15100 Birchaven Lane Findlay, OH 45840 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, resident interview, staff interview, and review of scheduled meal times, the facility failed to timely provide a breakfast meal to a resident. This affected one (#96) of 17 residents on the Cedar Unit of the facility. The facility census was 116. Findings include: Interview on 12/17/19 at 9:35 A.M. with Resident #96 revealed he had not eaten breakfast yet. Resident #96 revealed he always ate in his room and did not know what was taking so long for his food to arrive. Observation on 12/17/19 at 10:12 A.M. revealed State Tested Nurse Aide (STNA) #760 brought Resident #96's breakfast tray to his room. Interview on 12/17/19 at 10:18 A.M. with STNA #760 stated she was not sure why Resident #96's breakfast was given to him so late, however she had to wait on the food from the kitchen. STNA #760 revealed she knew Resident #96 had been awake in bed since at least 6:00 A.M.and he had not eating anything she knew that day. STNA #760 stated hall trays for Cedar Unit are out between 9:00 A.M. and no later than 9:30 A.M., and verified Resident #96's breakfast tray was given too late. Review of an undated facility meal times schedule revealed breakfast carts left the kitchen for the Cedar Unit at 7:15 A.M. and breakfast was served on the Cedar Unit between 7:30 A.M. and 9:00 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365973 If continuation sheet Page 3 of 5 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 365973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchaven Retirement Village 15100 Birchaven Lane Findlay, OH 45840 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 Based on medical record review, observation, and staff interview, the facility failed to ensure staff were wearing the proper personal protective equipment (PPE) for ordered isolation precautions. This affected one resident (#425) of two residents reviewed for transmission-based precautions. The facility census was 116. Residents Affected - Few Findings include: Review of the medical record for Resident #425 revealed an admission date of 11/29/19. Diagnoses included chronic obstructive pulmonary disease, malignant neoplasm (cancer) of the lung, and respiratory failure. Review of the admission Minimum Data Set (MDS) assessment, dated 12/06/19, revealed Resident #425 had no cognitive impairment. The resident was also identified to have cancer and be receiving chemotherapy. Review of the physician orders dated 12/13/19 revealed an order for strict neutropenic precautions due to the high risk of infection related to chemotherapy. Observation on 12/17/19 at 10:22 A.M., revealed Housekeeping Aide (HKA) #250 was inside Resident #425's room wearing an isolation gown and gloves. There was no mask on the staff member while providing services in the resident's room. Interview on 12/17/19 at 10:31 A.M., with HKA #250 revealed the housekeeping staff was told when entering an isolation room, they should be wearing an isolation gown and gloves, and they did not need to wear the masks the nursing staff wears when caring for residents. Interview on 12/17/19 at 1:50 P.M., with Assistant Director of Nursing (ADON) #260 revealed Resident #425 had recently began a round of chemotherapy and was placed in neutropenic precautions for the high risk of infection the resident had due to the treatment. The oncology physician wrote the order asking for isolation gowns, masks, and gloves to be worn in the resident's room. ADON #260 further reported isolation precautions were discussed in unit huddle meetings which included nursing staff, however not ancillary staff such as housekeeping. Additionally, ADON #260 reported signs are placed on the door of resident's in isolation stating, see nurse before entering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365973 If continuation sheet Page 4 of 5 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 365973 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchaven Retirement Village 15100 Birchaven Lane Findlay, OH 45840 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation and staff interview, the facility failed to have the appropriate chair to table height during dining for five residents (#10, #33, #44, #87, and #95) of 27 residents reviewed for dining in the Cedar/Dogwood dining area. The facility census was 116. Findings include: Observation on 12/15/19 at 11:58 A.M. in the Cedar Dogwood Dining room revealed six dining tables in the dining room. Observation of Resident #33 revealed the table she was sitting at was at her axilla (armpit). The resident was observed to be having difficulty feeding herself as she was sitting in her wheelchair and had to reach up over the table. Observation of four other residents (#10, #44, #87, and #95) revealed the table they were sitting at was the at the same height as Resident #33. All of the four residents had to reach up and over the table ledge to feed themselves. Interview on 12/15/19 at 12:18 P.M. with the Hospitality Aid (HA) #100 confirmed the tables were above the breast line of the five residents (#10, #33, #44, #87, and #95). The HA #100 confirmed it was hard for the residents to eat with the height of the table. Interview on 12/17/19 9:01 A.M. with the Assistant Director of Nursing (ADON) #300 confirmed the table was to high for Resident #33 and confirmed it would also be hard for Residents #10, #44, #87, and #95 to eat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365973 If continuation sheet Page 5 of 5