Health inspection·September 26, 2019

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record, resident interview, and staff interview, the facility failed to ensure new glasses were received in a timely manner for one (#8) out of one resident reviewed for vision. The facility census was 82. Residents Affected - Few Findings include: Review of Resident #8's medical record identified admission to the facility occurred on 01/18/19 with medical diagnosis including stroke. Review of the vision visit form, dated 06/06/19, identified Resident #8 had been assessed by the optometrist. The resident's chief complaint was his glasses were old and he would like a new pair. The form identified an eyeglasses order will be processed. Interview on 09/23/19 at 10:21 A.M., Resident #8 identified he saw the eye doctor several months ago and was told new glasses were ordered for him, but he has not gotten them and/or heard anything about them being available. Interview on 09/24/19 at 9:10 A.M., Social Services Designee (SSD) #63 confirmed Resident #8 was seen by the optometrist on 06/06/19 and the note identified glasses were ordered for Resident #8. SSD #63 confirmed no further up had been completed. SSD #63 identified she called the vision group whom visited on 09/24/19 and they confirmed there was a mix up and Resident #8's glasses were never ordered. SSD #63 stated the glasses would be ordered today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 2 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 medical record review, staff interview and review of a facility policy, the facility failed to ensure residents did not receive unnecessary psychotropic medications and as needed medications were not ordered for longer than 14 days. This affected two (#53, #23) of five residents reviewed for unnecessary medication. The facility census was 82. Findings include: 1. Medical record review revealed resident #53 admitted to the facility on [DATE] with a most recent readmission date of 07/20/19. Diagnoses included hypertension, dementia without behaviors, anxiety and depression. Review of Resident #53's physician orders revealed an orders dated 07/03/19 for the resident to be administered Seroquel (an anti-psychotic medication) 12.5 milligrams (mg) daily and an order dated 05/09/19 revealed the resident was to be administered Seroquel 12.5 mg daily at bed time. Both orders were discontinued when the resident discharged to an acute care hospital on [DATE]. The resident was readmitted on [DATE] and was ordered to to receive Seroquel 25 mg daily along with 12.5 mg at bedtime. Both orders were discontinued on 07/22/19 and the order was changed for the resident to receive 12.5 mg of Seroquel twice a day. None of the resident's orders listed an indication for the use of an anti-psychotic medication. Review of the resident's nursing progress notes and physician progress notes from 06/03/19 through 09/25/19, lacked any evidence of indications for the use of Seroquel. Review of the resident's behavior charting from 06/01/18 through 09/25/19, lacked any evidence for indications for the use of Seroquel. Interview on 09/25/19 at 1:04 P.M., State Tested Nursing Assistant (STNA) #64 revealed Resident #53 did not have any behaviors. STNA #64 stated the resident became anxious when she was scheduled to leave the facility for an appointment. Interview on 09/25/19 at 1:08 P.M., Licensed Practical Nurse (LPN) #181 revealed Resident #53 did not have any behaviors. LPN #181 stated the resident experienced anxiety at times when she was having increased back pain. Interview on 09/25/19 at 1:11 P.M., Registered Nurse (RN) #136 revealed she was the Unit Manager for Resident #53's hall. RN #136 revealed Resident #53 did not have any behaviors. RN #136 stated the resident was depressed over her current situation and experienced anxiety related to her chronic back pain and pending surgery. Additionally, Resident #53's physician orders revealed an order dated 07/29/19 for the resident to be administered Ativan (an anti-anxiety medication) 0.5 mg three times a day as needed. Review of the resident's medical record revealed no evidence the medication was limited to 14 days or the physician provided rational for the continued use beyond 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 3 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 Review of the resident's 08/2019 and 09/2019 Medication Administration Record (MAR) revealed the resident was administered Ativan 0.5 mg on 08/07/19 at 2:01 P.M. and 8:13 P.M., 08/25/19 at 5:16 A.M., 08/29/19 at 11:46 A.M., and on 09/01/19 at 10:36 P.M., 09/03/19 at 7:57 A.M., 09/10/19 at 6:32 A.M. and 09/14/19 at 8:05 A.M. No documentation of non-pharmacological interventions attempted prior to the administration of the Ativan was observed in the medical record. Residents Affected - Few Interview on 09/26/19 at 3:13 P.M., the Director of Nursing (DON) confirmed the resident received the above listed doses of as needed Ativan without documented evidence staff attempted non-pharmacological interventions prior to administering the medication. The DON further confirmed the resident's as needed Ativan order was not limited to 14 days and there was no rational documented by the resident's physician to continue the medication beyond 14 days. 2. Review of Resident #23's medical record revealed she admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and dementia with behavioral disturbance. Review of Resident #23's physician's orders revealed on 02/06/19 she received orders for Ativan 25 mg as needed (PRN). On 04/05/19 Resident #23 was ordered Ativan 25 mg PRN before bathing. The prescription did not document the required rationale and determined duration to extend both PRN anti-anxiety orders past the allotted 14 days. Interview on 9/26/19 at 3:13 P.M., the DON verified the prescriber did not provide a rationale or determine a duration for the PRN anti-anxiety medication that was required after 14 days. Review of a facility policy titled Psychotropic Medication Policy and Procedure, undated, revealed psychotropic medications would not bed used unless the medication was necessary to treat a specific condition that was diagnosed and documented in the clinical record. The policy further stated residents would not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions had failed to address the resident's target behavioral goals. Further review of the policy revealed PRN orders for psychotropic medications would be limited to 14 days unless the physician identified the rationale to extend the medication beyond 14 days. PRN anti-psychotic medication would be limited to 14 days and would not be renewed unless the physician evaluated the resident for appropriateness of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 4 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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, staff interview, and review of facility policy, the facility failed to timely notify the physician of abnormal laboratory test results for three (#7, #24 and #133) of four residents reviewed for urinary tract infections. The facility census was 82. Findings include: 1. Review of Resident #24's medical record identified admission to the facility occurred on 11/02/18. Diagnoses included dementia, urinary tract infection history, anxiety, major depression and insomnia. Review of progress notes and physician's orders dated 08/22/19 identified Resident #24 had foul smelling urine and was having increased agitation and restlessness. The physician was noted to order a urinalysis test to determine if an infection was present. The record identified on 08/23/19 at 1:23 A.M. Resident #24 was straight catheterized to obtain a urine sample. The laboratory testing results, dated 08/23/19 at 11:55 A.M. revealed they received Resident #24's urine sample. The testing report identified the culture was completed on Sunday 08/25/19 at 8:22 A.M. and was sent to the nursing facility on 08/25/19 at 10:01 A.M. The progress notes and the laboratory report dated 08/25/19 identified no evidence the physician was notified of the positive urinalysis results until 08/26/19 (Monday), when they ordered an antibiotic for a urinary tract infection. The report evidenced the nursing staff faxed the results on Sunday 08/25/19. Interview with the Director of Nursing (DON) on 09/24/19 at 1:09 P.M. confirmed the staff faxed and did not call the physician when Resident #24's urinalysis test was positive. 2. Review of Resident #133's medical record identified admission to the facility occurred on 09/06/19. Diagnoses included urinary incontinence, high blood pressure and Uranus syndrome. Review of Resident #133's medical record revealed a urinalysis was collected from Resident #133 on 09/11/19. The laboratory test identified the facility was notified of the positive results of the urinalysis on 09/12/19. The culture and sensitivity results returned on 09/15/19. The record identified the nursing staff faxed the physician the results on 09/15/19 with no evidence of telephone notification. The record identified the physician was not contacted by phone until 09/16/19, when an antibiotic was started. Interview on 09/24/19 at 1:09 P.M. the DON confirmed the staff faxed and did not call the physician when Resident #133's urinalysis test was positive. The DON confirmed the nursing staff should be calling and not faxing positive results. 3. Medical record review revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two, multiple sclerosis and chronic scenic heart disease. Review of a urinalysis with a culture and sensitivity, collected for the resident on 09/14/19, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 5 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 revealed the laboratory faxed the final results of the test to the facility on [DATE] at 10:35 A.M. The results revealed the resident had a urinary tract infection. Facility staff did not notify the resident's physician of the positive results until 09/17/19 and the resident was started on an antibiotic. Interview on 09/25/19 at 1:25 P.M., Registered Nurse (RN) #136 revealed staff were expected to call the physician with any abnormal lab reports. RN #136 confirmed staff should have called Resident #7's physician on 09/16/19 and notified him of the resident's positive urinalysis with a culture and sensitivity. Review of an undated facility policy titled Obtaining Lab Samples and Reporting of Values revealed any lab value that fell outside of the normal range limit, as indicated on the lab report, were supposed to be faxed to the primary care physician (PCP) as well as called to the PCP to ensure prompt attention to the results. Further review revealed any lab value identified as critical by the lab were phoned by the lab to the nurse who was supposed to notify the PCP immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 6 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the medical record, and review of the hospice contract, revealed the facility failed to ensure the hospice plan of care and visit notes were available in the facility for one (#59) of one resident reviewed for hospice services. The facility identified 10 residents were receiving hospice services. The facility census was 82, Findings include: Review of Resident #59's medical record revealed she admitted to the facility, on 08/02/19. Diagnoses included dementia, epilepsy, major depressive disorder, and bradycardia. She was receiving hospice services at the time of admission. Review of Resident #59's Minimum Data Set (MDS) assessment, dated 08/08/19, revealed she was seriously cognitively impaired. The assessment identified Resident #59 was receiving hospice. Further review of Resident #59's medical record lacked any evidence of her hospice plan of care and visit notes. During an interview on 09/25/19 02:11 at P.M., Licensed Practical Nurse (LPN) #56 revealed hospice was to keep their documentation in Resident #59's paper chart. LPN #56 stated hospice did not keep a separate binder nor was their documentation scanned to the electronic medical record. Interview on 9/25/19 at 4:04 P.M. with Social Worker #131 revealed the facility had requested and just received the hospice documentation from the hospice provider on 9/25/19 at 2:30 P.M. Social Worker #131 confirmed the facility had no hospice documentation in the record prior to [NAME]. Review of the hospice contract dated 02/27/18 revealed hospice shall provide the nursing facility with the following: a copy of the most recent plan of care, a copy of the hospice election form and advanced directives, names and contact information for hospice personnel, instructions on how to access the hospice's twenty four hour on call system, a copy of hospice medication information specific for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 7 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 observation of medication administration, medical record review, staff interview and review of a facility policy, the facility filed to ensure staff followed infection control policy when obtaining resident's blood glucose levels and administering insulin. This affected one (#56) of five resident's observed for medication administration. The facility identified three residents who received blood glucose level checks. The facility census was 82. Residents Affected - Few Findings include: Medical record review revealed Resident #56 admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two, chronic kidney disease and hypertension. Review of the resident's physician orders revealed an order dated 08/17/18 for staff to check the resident's blood glucose level four times a day. Review of an order dated 04/25/19 revealed the resident was to be administered 10 units of Novolog insulin before meals. Observation on 09/25/19 at 4:16 P.M., revealed Licensed Practical Nurse (LPN) #181 obtained a glucometer (device used to obtain a sample of blood for glucose testing) out of the medication cart and proceeded to Resident #56's room. LPN #181 obtained the resident's blood glucose level then returned to the medication cart and placed the glucometer back into the top drawer. LPN #181 was not observed to clean the glucometer prior to or after obtaining the resident's blood glucose level. LPN #181 then proceeded to prepare the resident's Novolog insulin for administration. LPN #181 took the opened vile of Novolog out of the drawer and inserted a needle into the rubber stopper and drew up 10 units of the insulin. LPN #181 then proceeded to the resident's room and administered the insulin to Resident #56. LPN #181 was not observed to clean the rubber stopper on the vile of insulin prior to obtaining the resident's dose of insulin. Interview on 09/25/19 at 4:27 P.M., LPN #181 revealed glucometers were used for multiple residents and were cleaned daily on the night shift. LPN #181 confirmed she did not clean the glucometers between use for multiple residents, prior to obtaining Resident #56's blood glucose level. LPN #181 further revealed insulin vile rubber stoppers were supposed to be cleaned with alcohol prior to obtaining a dose of insulin. LPN #181 further confirmed she did not clean the rubber stopper of the Novolog insulin vile prior to obtaining Resident #56's insulin. Review of a facility policy titled Guidelines and Policy for Glucometer Use, dated 01/2012, revealed the facility would promote the safe and efficient measurement of blood glucose levels for residents. Further review revealed staff were supposed to clean glucometers with a disinfectant wipe and allowed to dry at least three minutes before using it on another resident. Review of a facility policy titled Subcutaneous Medication Administration, dated 07/01/12, revealed staff were supposed to clean the rubber stopper of a vile with alcohol prior to obtaining the dose of medication required for injection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 8 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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, and review of facility policy, the facility failed to follow up with the physician regarding the continued use of a prophylactic antibiotic in the presence of infections not treated by the antibiotic. This affected one (#43) of six residents reviewed for antibiotic use. The facility census was 82. Residents Affected - Few Findings include: Review of Resident #43's medical record identified admission to the facility on [DATE]. Diagnoses included rectocele, recurrent urinary tract infections, and major depression. Review of the urology notes dated 11/06/18 identified Resident #43 has recurrent urinary tract infections, significant rectocele and was not candidate for surgical interventions. The recommendations identified Resident #43 would require catheterization to obtain all urine specimens. The notes further identified a prophylactic antibiotic, trimethoprim 100 milligrams daily was ordered with follow up to occurred in six months. The note identified the appointment was set for 05/13/19. Review of laboratory report dated 01/05/19 identified Resident #43 had a positive stool test for Clostridium difficule (C-Diff). Review of the medical record revealed the facility did not follow up with the urologist to inform of the presence of the C-diff to determine if the prophylactic antibiotic treatment should continue. Review of a laboratory report dated 06/17/19 identified a urinalysis culture and sensitivity revealed the resident's urine was positive for Escheria Coli. The sensitivity revealed the bacteria was resistant to the treatment of trimethoprim. The notes contained no evidence the urologist was contacted regarding the continued use of the trimethoprim daily. Review of laboratory report dated 06/25/19 identified Resident #43 had another stool test positive for C-Diff. The notes identified the prophylactic antibiotic continued with no follow up occurring with the urologist to inform of the development of antibiotic-resistant organism. Review of a urinalysis test dated 09/13/19 identified Resident #43 test was negative for a urinary infection. Review of Resident #43's medication administration record dated 09/25/19 confirmed Resident #43 remains receiving the trimethoprim 100 mg daily. Interview on 09/25/19 at 4:04 P.M., the Director of Nursing (DON) identified the facility has established criteria for urinary tract infections and when antibiotic use is appropriate. The interview confirmed Resident #43 did not have a current urinary tract infection, however remains on the antibiotic. The interview confirmed there was no evidence Resident #43 was evaluated for continued use of the prophylactic antibiotic following the laboratory tests which were positive for C-Diff and the urinalysis culture and sensitivity which identified the antibiotic was not effective against the bacteria present. Review of the undated facility policy titled Criteria of Urinary Tract Infections, Lower Respiratory Tract Infections and Skin Infections, revealed unnecessary antibiotic use can result in side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 9 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 effects and drug resistant bacteria. The policy indicated the minimum criteria for initiation of antibiotic in long term care residents identified at least one of the following: fever greater than 100 degrees Fahrenheit, new costovertebral tenderness (back kidney area), rigors (chills) and new onset of delirium. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 10 of 11 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 366166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Care Village Health Care Center 2000 Center St Ashland, OH 44805 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, facility policy review, and staff interview, the facility failed to provide the pneumococcal vaccination to one (#23) of five sampled residents. The facility census was 82. Residents Affected - Few Findings include: Review of Resident #23's medical record identified admission occurred on 01/18/19. Diagnoses included Alzheimer's disease, dementia, chronic kidney disease and stroke. The record identified Resident #23's daughter signed a consent and requested for her to receive the pneumococcal (PCV 13) vaccine on 01/18/19. The record lacked any evidence Resident #23 received the vaccine. Interview with the facility Director of Nursing occurred on 09/25/19 at 4:04 P.M. and confirmed Resident #23 did not receive the PCV13 vaccine and this was missed by the staff. Review of the facility policy titled Pneumococcal Vaccination Policy, dated 04/25/16, identified each resident will be offered the vaccination upon admission, in accordance with the center for Disease control (CDC) guidelines. Interview with the facility Director of Nursing occurred on 09/25/19 at 4:04 P.M. The interview confirmed Resident #23 did not receive the PCV13 vaccine and this was missed by the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366166 If continuation sheet Page 11 of 11