Health inspection·December 5, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few invasive ventilator in the facility where she had an endotracheal tube or a trachesotomy tube inserted into her body. Resident #24 states she used the machine observed in her room at night. Review of Resident #24's MDS assessments revealed the 11/09/23 modified quarterly MDS was coded as the resident used an invasive mechanical ventilator while a resident. Additional review of Resident #24's MDS assessments dated 12/12/23, 12/17/23, 01/05/24, 02/07/24, 05/60/24, 06/21/24, and 08/26/24 all coded the resident used an invasive mechanical ventilator. Review of the Beyond ResPlus B-30P Bi-Level PAP user manual, version No.: U.S./20201218/A1, revealed the BiPap was designed for delivery of positive airway pressure to provide non-invasive ventilation for adult patients with respiratory insufficiency or obstructive sleep apnea (OSA) in home or hospital environment. Interview with MDS Coordinator #57 on 12/04/24 at 3:52 P.M. verified Resident #24's MDS assessments were coded as invasive mechanical ventilation since 12/12/23. Interview with Corporate Nurse #102 on 12/05/24 at 9:35 A.M. verified the user manual revealed Resident #24's BiPap machine was a non invasive mechanical ventilator. Review of a government website at, https://www.ncbi.nlm.nih.gov/books/NBK560600/, last updated 08/08/23, revealed non-invasive ventilation has gained increased prominence in the management of a variety of conditions causing acute as well as chronic respiratory failure. Different modalities of non-invasive ventilation exist, with continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) being the most commonly used modes. Average volume-assured pressure support (AVAPS) is a relatively newer modality of non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, revealed, in section O0110F1, Invasive Mechanical Ventilator (ventilator or respirator), staff are to code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration in this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. Residents receiving closed-system ventilation include those residents receiving ventilation via an endotracheal tube (e.g., nasally or orally intubated) or tracheostomy. A resident who has been weaned off of a respirator or ventilator in the last 14 days or is currently being weaned off a respirator or ventilator, should also be coded here. Do not code this item when the ventilator or respirator is used only as a substitute for BiPAP or continuous positive airway pressure (CPAP). Further review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, revealed, in section O0110G1, Non-invasive Mechanical Ventilator, staff are to code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 2 of 8 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 366038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on staff interview and medical record review, the facility failed to to ensure resident Preadmission Screening and Resident Review (PASARR) documents were accurate regarding a resident's current conditions and diagnoses. This affected one (#15) of two residents reviewed for PASARR documents. The census was 42. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed an admission date of 07/27/24. Diagnoses included aphasia following cerebral vascular disease, bipolar disorder, depression, restless legs syndrome, poly-neuropathy, anxiety disorder, anemia, major depressive disorder, hypertension, epilepsy, migraine, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage. Review of Resident #15's medical record revealed the diagnoses of anxiety was present at the time of admission. Review of the 11/01/24 quarterly Minimum Date Set (MDS) assessment revealed Resident #15 was severely cognitively impaired and used a wheelchair to aid in mobility. Review of Resident #15's 07/30/24 PASARR document revealed there was no diagnosis of anxiety listed. Interview with Social Services Designee #77 on 12/04/24 at 3:56 P.M. verified Resident #15 anxiety diagnosis was not recorded on the 07/30/24 PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 3 of 8 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 366038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident with a change in their mental health condition. This affected one (#02) of two residents reviewed for PASARR documents. The facility census was 42. Findings include: Review of Resident #02's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including congestive heart failure, chronic pulmonary disease, type two diabetes mellitus without complications, post traumatic stress disorder (PTSD), brief psychotic disorder, adjustment disorder with mixed anxiety and depressed mood, and unspecified dementia moderate with psychotic disturbance. Review of Resident #02's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required set up assistance with eating. Resident #02 required supervision with oral hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers, and walking 10 feet. Resident #02 required moderate assistance with toileting, showering, and personal hygiene. Review of Resident #02's PASARR dated 09/01/23 revealed Resident #02 had mood disorder, panic or other severe anxiety disorder, and other psychotic disorder. Resident #02 did not have indications of serious mental illness. Review of Resident #02's diagnosis list dated 12/04/24 revealed Resident #02 had a diagnosis of PTSD that was added on 06/06/24 during Resident #02's stay at the facility. Review of Resident #02's chart from 09/01/23 to 12/04/24 revealed Resident #02 did not have a significant change PASARR or notification to the state mental health authority of Resident #02's new diagnosis of PTSD on 06/06/24. Review of Resident #02's psychiatric note dated 06/06/24 revealed Resident #02 had a new diagnosis of PTSD and was prescribed Prazosin one milligram (mg) for PTSD related to Resident #02 yelling when she was asleep. Review of Resident #02's physician note dated 06/12/24 revealed Resident #02 was recently prescribed Prazosin one mg at bedtime for PTSD. Interview with the Director of Nursing 12/04/24 at 2:04 P.M. verified Resident #02 received a new diagnosis of PTSD on 06/06/24 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #02's new diagnosis of PTSD on 06/06/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 4 of 8 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 366038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, review of a facility provided resident list, and review of a menu spreadsheet, the facility failed to ensure residents received food portions based on the menu spreadsheet. This affected 17 (#02, #04, #05, #06, #07, #09, #11, #12, #13, #14, #23, #30, #32, #33, #36, #38 and #40) of 17 residents that received mechanical soft or pureed diets in a facility census of 42. Findings include: Review of the facility's menu spreadsheet for lunch on 12/04/24 revealed mechanical soft diets were to receive four (4) ounces (oz.) of mechanical roast beef, two (2) oz. of gravy, 4 oz. of garlic mashed potatoes, 4 oz. of Normandy vegetable blend, and one slice of wheat bread. Further review revealed pureed diets were to receive 4 oz. of pureed roast beef, two and two-thirds oz. of pureed Normandy vegetable blend, two-thirds slice of pureed bread, and 4 oz. of mashed potatoes. Observation of tray line on 12/04/24 at 11:45 A.M. revealed Dietary Manager (DM) #34 serving residents during the lunch meal. DM #34 provided residents on a mechanical soft diet a 2 oz. scoop of mechanical roast beef, a 4 oz. scoop of garlic mashed potatoes, a 4 oz. scoop of Normandy vegetable blend, and a roll. Further observation of tray line revealed pureed diets received a 2 oz. scoop of pureed roast beef, a 2 oz. scoop of pureed Normandy vegetable blend, and a 4 oz. scoop of mashed potatoes. Interview with DM #34 on 12/04/24 at 11:45 A.M. verified mechanical soft diets received a 2 oz. scoop of mechanical roast beef, a 4 oz. scoop of garlic mashed potatoes, a 4 oz. ounce scoop of Normandy vegetable blend, and a roll. DM #34 stated he mixed the gravy into the mechanical soft roast beef and that was included in the 2 oz. scoop of mechanical roast beef that was provided to residents on mechanical soft diets. DM #34 also verified pureed diets received a 2 oz. scoop of pureed roast beef, a 2 oz. scoop of pureed Normandy vegetable blend, and a 4 oz. scoop of mashed potatoes. DM #32 stated he did not have any pureed bread for residents that received pureed diets on 12/04/24. Review of a list of residents by diet type dated 12/04/24 revealed Resident #02, Resident #05, Resident #07, Resident #09, Resident #11, Resident #06, Resident #30, Resident #32, Resident #33, Resident #36, Resident #38 and Resident #40 received mechanical soft diets and Resident #04, Resident #12, Resident #13, Resident #14 and Resident #23 received pureed diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 5 of 8 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 366038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of a meal spreadsheet, and policy review, the facility failed to serve food as prescribed for residents on a controlled carbohydrate therapeutic diet. This affected 15 (#8, #3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) of 15 residents who received a controlled carbohydrate diet. The facility total census was 42. Findings Included: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety, somnolence, migraines, fibromyalgia, encephalopathy, diabetes, anxiety disorder, history of cellulitis of limb, morbid obesity, irritable bowel, cognitive impairment, chronic kidney disease, chronic pain, and psychosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderately impaired cognition and required set assistance with meals. Review of Resident #8's current physician orders revealed the resident had an order for a controlled carbohydrate diet, received insulin via sliding scale, and was ordered the anti-diabetic medication Januvia 200 milligrams one tablet a day. Review of breakfast spreadsheets dated 11/28/24, 11/30/24, and 12/03/24 revealed reduced calorie syrup was to be served for residents receiving a controlled carbohydrate diet. Observation on 12/03/24 at 8:00 A.M. revealed Resident #8 was feeding herself the breakfast meal including pancakes. The meal ticket listed Residents #8 was on a controlled carbohydrate diet and was to receive reduced calorie syrup. The syrup observed on the resident's tray was regular, non-reduced calorie syrup. Observation on 12/03/24 at 8:13 A.M. revealed the Dietary Aide was #32 placing regular syrup on all residents' meal trays, including 14 (#3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) other residents. Interview of 12/03/24 at 8:12 A.M. with Certified Nurse Aide (CNA) #92 verified Resident #8 had regular, non-reduced calorie syrup on her tray and the meal ticket listed the resident should have received reduced calorie syrup. Interviews on 12/03/24 at 8:15 A.M. with Dietary Aide #32 and [NAME] #27 revealed there was no reduced calorie syrup for any of the 15 (#8, #3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) residents who had physician orders for a controlled carbohydrate diet. Both staff members confirmed there was only regular calorie syrup available in the storage room and the food delivery was due that day. Dietary Aide #32 and [NAME] #27 were unsure when the last time reduced calorie syrup was available to be served to the 15 residents on a controlled carbohydrate diet. Interview on 12/03/24 at 2:07 P.M. with Dietary Manager (DM) #34 verified there had been no recent deliveries and no upcoming delivery of reduced calories syrup. DM #34 verified he was not notified there had been an outage of the reduced calorie syrup and had been two breakfast meals the prior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 6 of 8 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 366038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123 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 0808 week, 11/28/24 and on 11/30/24, requiring reduced calorie syrup. Level of Harm - Minimal harm or potential for actual harm Medical record review for 14 additional residents including; Resident #3, Resident #28, Resident #33, Resident #25, Resident #37, Resident #7, Resident #32, Resident #16, Resident #2, Resident #29, Resident #147, Resident #145, Resident #148, and Resident #18 revealed all residents had a physician order to receive a controlled carbohydrate diet. Residents Affected - Some Review of facility policy titled, Therapeutic Diets, dated October 2017, revealed a therapeutic diet is ordered by a physician as part of a treatment for a disease and to modify the specific nutrients in the diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 7 of 8 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 366038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123 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 and policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner to prevent foodborne illness. This affected all 42 residents who received food from the facility kitchen. The facility census was 42. Findings include: 1. Observation of the milk cooler in the kitchen on 12/02/24 at 9:26 A.M. revealed there were two gallons of milk that were opened with an expiration date of 11/30/24. Interview on 12/02/24 at 9:26 A.M. with [NAME] #27 verified there were two gallons of open milk with an expiration date of 11/30/24 in the milk cooler in the kitchen. Review of the facility's food receiving and storage policy, dated October 2017, revealed food should be stored in a manner that complies with safe food handling practices. 2. Observation on 12/04/24 from 8:02 A.M. to 8:22 A.M. revealed Dietary Manager (DM) #34 was serving breakfast meal to all residents. DM #34 wore gloves and had a towel draped on his shoulder. DM #34 had facial hair and was not wearing a protective facial hair restraint. DM #34 was observed to serve food onto plates for residents with gloved hands then touched the counter, wiped his face and head with the towel, and returned the towel to his shoulder area. Continued observation revealed DM #34 placed toast with his gloved hands onto the serving plates and took the plates to residents in the dining room with his gloved thumb extending onto the plates. DM #34 returned to the food serving area, wiped his face with the towel, and with the same gloved hands put toast onto the next resident's plate. DM #34 was not observed to change his gloves or wash his hands until the end of the meal service. Interview on 12/04/24 at 8:30 A.M. with DM #34 verified he had full facial hair and should have worn a facial hair covering. DM #34 verified he used a towel around his shoulder to wipe perspiration from his head and face. DM #34 verified he placed the toast on resident's plates with the same gloved hands after having wiped his perspiration onto the towel. DM #34 verified he served residents food to the table side and had his thumb extending into the plate with the same gloved hands used to continue food plating. DM #34 verified he did not change his gloves or wash his hands until the end of the meal service. Review of facility policy titled, Food Preparation and Service, dated April 2019, revealed food preparation staff are to adhere to proper hygiene. Gloves are worn when handling food directly and changed between tasks. Food service staff wear hair restraints, (hair nets and beard restraints), so hair does not contact food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366038 If continuation sheet Page 8 of 8