Health inspection·March 3, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some schedules were being changed in March 2022. LPN #128 first stated residents were only getting one shower because of COVID to limit exposure by residents crossing the hall. When asked if it was safe for residents to go to the shower one day a week why it would not be safe to go to the shower room other days no explanation was provided. When asked prior to the new schedule being developed if residents were interviewed to determine their preference for showers LPN #128 stated residents were placed on the same shower schedule they were on before COVID or when on other units but staff did not necessarily interview residents to determine current preferences. Based on interview, record review, and policy review , the facility failed to offer residents a preference in bathing frequency. This affected four residents (Resident #28, #75, #77, and anonymous) of four residents reviewed for choices. Findings include: 1. Review of Resident #75 medical record revealed the resident was admitted [DATE] with diagnoses including muscle weakness, anemia, chronic pain syndrome, restless leg syndrome, and kidney disease. Review of Resident #75's plan of care, dated 01/28/22, revealed the resident had a self care deficit due to tires easily most days, needs assist with bathing and dressing, decreased strength and endurance, muscle weakness, and osteoarthritis. Intervention included provide assistance while continually monitoring abilities and limitations with regard to bathing, dressing, and grooming daily and as needed. Review of the 02/04/22 admission Minimum Data Set (MDS) assessment revealed the resident was independent for daily decision making, extensive assist of one for personal hygiene, and physical help of one in part for bathing activity. It was very important to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #75's 02/04/22 Care Conference record revealed the resident could choose when he/she would like to bathe/shower, including frequency. Review of the 02/14/22 Observation Details revealed Resident #75 preferred a shower in the morning. Review of the resident plan of care summary included the resident preferred to get a shower in the morning. There was no indication of the resident's preferred frequency of bathing documented. Resident #75's medical record revealed she was transferred to the Garden Unit 02/23/22. Interview on 02/28/22 at 09:15 A.M. with Resident #75 revealed she would like two showers a week. No one asked her how many showers she wanted. She said she has asked is told she was on the list. Resident #75 revealed she had not received a shower or bath since transferring to the Garden Unit. Review of the bath/shower logs revealed no showers or baths had been provided to Resident #75 since the resident arrived on the Garden Unit 02/23/22. Interview on 02/28/22 at 09:56 A.M. with Registered Nurse #89 revealed they were giving one shower and one bed bath a week instead of two showers due to losing staff to COVID. Now that they had another aide the residents would get two showers a week. The facility did not ask how many baths/showers a resident would like a week but if requested they would give more. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 2 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/01/22 at 11:11 A.M. with Activities Assistant #79 revealed she does the preference interviews. She would ask the residents which type of bath they prefer and what time of day. She did not have a prompt to ask what frequency they would like bathed. She just learned today to ask how often. She did not know to ask the residents the frequency they wanted bathed. Interview on 03/03/22 at 10:24 A.M. with Registered Nurse #118 and Licensed Practical Nurse #149 verified Resident #75's Care Conference record question can the resident choose when he/she would like to bathe/shower, including frequency was on the care conference sheet and Resident #75 answered yes, however, no one asked the question. Review of the facility's Bathing Frequency policy, last reviewed 08/20/21, revealed residents are interviewed during the admission process regarding the frequency they like to bathe/shower. The frequency of the bath or shower is reviewed at least quarterly during the care planning conference with the resident. Changes are implemented if indicated by the residents choice. 2. Review of Resident #77 revealed the resident was admitted [DATE] with diagnoses including age related physical debility, chronic kidney disease, venous insufficiency, and morbid obesity. Review of Resident #77's plan of care, dated 08/05/21, revealed a self care deficit plan of care related to tires easily most days, needs assist with bathing and dressing, decreased strength and endurance, hoyer transfer, congested heart failure, morbid obesity, decreased mobility, unsteadiness, on feet and muscle weakness. Intervention included provide assistance while continually monitoring abilities and limitations with regard to bathing, dressing, and grooming and daily and as needed. Review of the 01/31/22 Quarterly MDS assessment revealed the resident was independent for daily decision making, extensive assist one for personal hygiene, and physical help in part of two for bathing. It was very important to choose between a tub bath, shower, bed bath, or sponge bath. Interview on 02/28/22 at 11:17 A.M. with Resident #77 revealed she would like two bed baths and one shower a week. No one had asked her how many times she wanted bathed a week. She currently gets a shower and a bed bath weekly. Interview on 03/01/22 at 10:57 A.M. with State Tested Nurse Aide (STNA) #96 said about six months into the COVID pandemic they started only giving one shower a week due to staff quitting. That was about a year and a half ago. This week they are starting to provide two showers a week. STNA #96 verified Resident #77 has been getting one bed bath and one shower a week, not one shower and two full bed baths as preferred. Interview on 03/01/22 at 11:11 A.M. with Activities Assistant #79 revealed she does the preference interviews. She would ask the residents which type of bath they prefer and what time of day. She did not have a prompt to ask what frequency they would like bathed. She just learned today to ask how often. She did not know to ask the residents the frequency they wanted bathed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 3 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure all residents were provided the option to attend the Resident Council meetings, nor were resident concerns documented and no evidence was provided indicating concerns were addressed timely. This had the potential to affect 79 of 85 residents residing in the facility, as Resident #11, #20, #22, #28, #29, and #78 regularly attended resident council. Residents Affected - Some Findings include: Review of Resident Council Meeting minutes for February 2021 through February 2022 revealed no resident concerns were documented in the meeting minutes. There were between four and seven residents in attendance at each meeting and the list of residents had very little variation month to month. Residents #11, #20, #22, #28, #29, and #78 attended regularly. On 03/01/22 at 10:05 A.M. interview with Social Worker #74 confirmed there were several concerns voiced during Resident Council meetings that she did not document in the meeting minutes. She stated resident concerns were verbally reported to the unit managers to address and there was no formal concern log. On 03/02/22 at 1:09 P.M., observation of a resident council meeting revealed Residents #16, #22, and #78 were in attendance. Social Worker #74 began the meeting, provided a summary of infection control updates, informed residents of upcoming ancillary services visits, informed residents of upcoming activities, and concluded the meeting by asking residents if they had any concerns with anything. Social Worker #74 wrote the resident concerns on a piece of notebook paper. On 03/02/22 at 1:43 P.M., interview with Social Worker #74 verified she recorded resident concerns on a piece of notebook paper. She stated she wrote down resident concerns and checked them off after they were addressed, then she would shred the notebook paper once all concerns were resolved. She confirmed again that she did not document resident concerns in the meeting minutes. She stated she did not used to do Resident Council and that was how she was trained to conduct the meetings and record the minutes. Social Worker #74 stated she was given a list of residents and told those were her residents for Resident Council. Those were the residents she invited to the meetings and interviewed when she did room to room visits during COVID-19 outbreaks. On 03/03/22 from 8:14 A.M. to 8:25 A.M., interviews with Residents #41, #72, and #75 revealed they had not been invited to attend Resident Council meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 4 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure advance directives were accurately documented on all sources. This affected three residents (Resident #27, #40, and #66) of 24 residents reviewed for advanced directives. Findings include: 1. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including acute systolic heart failure, atrial fibrillation, acute respiratory, head injury, and dysphagia. Review of Resident #66 signed advanced directive dated 11/10/21 revealed the resident's code status was do not resuscitate comfort care (DNRCC). Review of the facility resident report sheet undated revealed Resident #66's code status was DNRCC-A. Interview on 02/28/22 at 2:28 P.M, with Licensed Practical Nurse (LPN) #16 and LPN#154 revealed the residents code statuses were documented on the report sheet board, and electronic medical records. The LPN's confirmed the report sheet was inaccurate and Resident #66's was a DNRCC not an DNRCC-A and they would correct the report sheet. 2. Record review revealed Resident #27 was admitted the facility on 09/20/21 with diagnoses including intertrochanteric fracture right femur, edema, fluid overload, embolism and thrombosis, acute respiratory failure, and heart disease. Review of Resident #27's signed advance directive dated 09/22/21 revealed the resident's code status was DNRCC-A. Review of the resident report sheet undated revealed Resident #27's code status was DNRCC. Interview on 02/28/22 at 2:28 P.M. with LPN #16 and LPN# 154 revealed the residents code status were documented on the report sheet, board, and electronic medical records. The LPN's confirmed the report sheet was inaccurate and Resident #27 was an DNRCC-A not an DNRCC and they would correct the report sheet. 3. Review of Resident #40 medical record revealed an admission date of 01/05/22 with diagnoses of acute on chronic diastolic (congestive) heart failure, polyneuropathy, and type two diabetes mellitus. Review of Resident #40 Do Not Resuscitate (DNR) order form revealed the resident and physician signed the order on 01/06/22 for the resident to have a DNR comfort care protocol to be affective immediately. Review of the Rehab hall (the hall where Resident #40 resides) census and code status board revealed the facility had identified the resident as a Do Not Resuscitate- Comfort Care Arrest (DNR-CCA). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 5 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 0578 Level of Harm - Minimal harm or potential for actual harm Interview on 02/28/22 at 11:43 A.M. with Registered Nurse #99 revealed that the facility uses the census and code status board as a quick way to identify someone's code status in an emergency. She confirmed that the facility had incorrectly listed Resident #40 as a DNR-CCA on the code status board and he should be listed as a DNR-CC. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 6 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of Skilled Nursing Facility (SNF) beneficiary non-coverage notifications and interview, the facility failed to consistently provide written notification of services that would no longer be covered by Medicare Part A. This affected two residents (Residents #58 and #68) of three residents reviewed for notification of termination of Medicare Part A services. Residents Affected - Few Findings include: 1. Review of a Notice of Medicare Non-Coverage indicated Resident #58's effective date of coverage of skilled services would end 10/28/21. Services which would no longer be covered included Speech Therapy (ST), Occupational Therapy (OT), Physical Therapy (PT) and skilled nursing services. There was no signature on the form but a hand-written note indicated see verbal notice attached. Review of a SNF Advance Beneficiary Notice of Non-Coverage (SNFABN) indicated beginning on 10/29/21, Resident #58 might have to pay out of pocket for his care if he did not have other insurance that might cover those costs. A box was checked indicating the care listed on the notice was not desired. It indicated an acknowledgment Resident #58 was not responsible for paying and could not appeal to see if Medicare would pay. There was no signature but there was a hand-written notation to see the verbal notice attached. An attached form indicated on 10/26/21 at 4:00 P.M., Social Service Designee #74 informed the Responsible Party via phone that skilled services would be ending on 10/28/21 and financial liability would begin on 10/29/21. If not in agreement, an expedited appeal could be submitted by noon on 10/27/21 (phone number provided). If the deadline was missed, contact information was provided to inquire about other appeal rights. The notice was signed by SSD #74 on 10/26/21. On 03/02/22 at 9:25 A.M., SSD #74 stated once she learned a resident was going to be cut from Medicare Part A covered services she notified the resident, or if not able to notify the resident, she notified a family member or responsible party. If the family/responsible party was not available in the facility she called and notified the responsible party verbally so they had time to appeal the decision by noon the next day if they desired. The information from the notices was read to the responsible party over the phone along with the process for appeal and liability. The written notification was left at the nursing station or given directly to family if they were in facility so the notification could be signed. Some families picked the notifications up and signed them and some did not come to the facility to pick them up. SSD #74 stated she did not know the notifications had to be provided in writing. 2. Review of a Notice of Medicare Non-Coverage indicated Resident #68's effective date of coverage of skilled services would end 11/02/21. Services which would no longer be covered included Speech Therapy (ST), Occupational Therapy (OT), Physical Therapy (PT) and skilled nursing services. There was no signature on the form but a hand-written note indicated see verbal notice attached. Review of a SNF Advance Beneficiary Notice of Non-Coverage (SNFABN) indicated beginning on 11/03/21, Resident #68 might have to pay out of pocket for her care if she did not have other insurance that might cover those costs. A box was checked indicating the care listed on the notice was not desired. It indicated an acknowledgment Resident #68 was not responsible for paying and could not appeal to see if Medicare would pay. There was no signature but there was a hand-written notation to see the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 7 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 0582 verbal notice attached. Level of Harm - Minimal harm or potential for actual harm An attached form indicated on 10/29/21 at 1:10 P.M., Social Worker #60 notified the Responsible Party via phone that skilled services would be ending on 11/02/21 and financial liability would begin on 11/03/21. If not in agreement, an expedited appeal could be submitted by noon on 11/01/21 (phone number provided). If the deadline was missed, contact information was provided to inquire about other appeal rights. The notice was signed by Social Worker #60 on 10/29/21. Residents Affected - Few On 03/02/22 at 9:25 A.M., SSD #74 stated once she learned a resident was going to be cut from Medicare Part A covered services she notified the resident, or if not able to notify the resident, she notified a family member or responsible party. If the family/responsible party was not available in the facility she called and notified the responsible party verbally so they had time to appeal the decision by noon the next day if they desired. The information from the notices was read to the responsible party over the phone along with the process for appeal and liability. The written notification was left at the nursing station or given directly to family if they were in facility so the notification could be signed. Some families picked the notifications up and signed them and some did not come to the facility to pick them up. SSD #74 stated she did not know the notifications had to be provided in writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 8 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 record review, observation, review of wound practitioner notes, interviews, and policy review, the facility failed to ensure pressure relieving interventions were in place per the plan of care, treatments were administered per orders, and assessments and staging of pressure ulcers were accurate. This affected one resident (Resident #27) of one resident reviewed for pressure ulcers Residents Affected - Few Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right and left femur, acute embolism and thrombosis, respiratory and heart failure, hypoxemia, anemia, and protein-calorie malnutrition. A. Review of Resident #27's plan of care for impaired skin integrity as evidence by stage III (full thickness loss extending through the dermis) right heel pressure ulcer dated 01/14/22, revealed the goal was to reduce the resident risk factors for further alterations in the skin integrity and the resident would experience progressive wound healing. The resident interventions included to elevate the heels of bed and offloading boot for right heel. The wound would be cleansed and a foam dressing applied daily and as needed. Review of wound practitioner note dated 01/26/22, revealed the resident had a stage III pressure ulcer to the right heel. The wound measured 5.5 cm by 4.0 cm by 0.1 cm with bloody drainage and 100% granulation. New orders to cleanse and apply a foam dressing daily and as needed. Order offloading boot to right foot. Observation on 02/28/22 at 9:54 A.M., with Licensed Practical Nurse (LPN) #154 revealed the resident was lying in bed. The resident's feet were not elevated, nor was there a boot on the right foot per the plan of care. The dressing was intact to the right heel; however, the dressing was not dated. Findings confirmed with LPN #154 during observation. Interview on 03/02/22 11:17 A.M. with LPN #154 revealed the heel boot order was not entered in the electronic medical record, however she was going to enter the orders so staff can sign off the orders to ensure boots are in-place every shift. B. Review of Resident #27's skin re-admission skin assessment completed on 01/14/22, revealed the resident was re-admitted with a 1.1 centimeter (cm) by 1 cm purple discolored area on the right heel. Review of Resident #27's plan of care for impaired skin integrity as evidence by stage III (full thickness loss extending through the dermis) right heel pressure ulcer dated 01/14/22, revealed the goal was to reduce the resident risk factors for further alterations in the skin integrity and the resident would experience progressive wound healing. The resident interventions included to assess and monitor for healing/deterioration. Review of an untitled sheet with the Residents name and site right heel dated 01/26/22 to 02/28/22 revealed the resident treatment was to cleanse the right heel with normal saline, pat dry, apply foam dressing daily. The box with etiology, description, and measurements was blank except for the weekly measurement. The wound was 2.0 cm by 2.0 cm by 0.0 on 01/26/22 and on 01/28/22 it was 1.6 cm by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 9 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 1.5 cm by 0.0 cm. There was no evidence of the etiology, description or staging of the wound. Level of Harm - Minimal harm or potential for actual harm Review of Resident #27's wound assessment ulcer information form dated 01/14/22 to 02/24/22 revealed the resident had an unstageable (full thickness tissue loss) pressure ulcer on the right heel. The pressure ulcer measured from 1.1 cm by 1.0 cm by 0.0 to 2.0 cm by 2.0 cm x 0.0 cm. The pressure ulcer had no depth on any of the weekly measurements On 02/02/22 to 02/16/22 the pressure ulcer was noted to have serosanguineous discharge and from 02/02/22 to 02/24/22 the wound bed had 75%-100% granulation and 75%-100% epithelization tissue. Residents Affected - Few Review of Resident #27's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an unstageable pressure ulcer. Review of the wound practitioner notes dated 01/26/22 to 02/23/22 revealed the following: • 01/26/22 the resident had a stage III pressure ulcer to the right heel. The wound measured 5.5 cm by 4.0 cm by 0.1 cm with bloody drainage and 100% granulation. New orders to cleanse and apply a foam dressing daily and as needed. Order offloading boot to right foot. • 02/02/22 the right heel measured 4.0 cm by 2.7 cm by 0.1 cm with serous drainage and 100% granulation. No new orders. • 02/09/22 the right heel measured 3.5 cm by 2.5 cm by 0.1 cm with serous drainage and 100% granulation. No new orders. • 02/16/22 the right heel measured 2.0 cm by 2.4 cm by 0.1 cm with serous drainage and 100% granulation. No new orders. • 02/23/22 the right heel measured 1.6 cm by 2.2 cm by 0.1 cm with serous drainage and 100% granulation. No new orders. Interview on 03/02/22 at 2:32 P.M. with LPN #154 revealed the facilities wound assessments were inaccurate including the depth, size, description of the wound, and the staging of the pressure ulcer on the Resident #27 pressure ulcer. The LPN reported the MDS dated [DATE] was inaccurate as well and the pressure was a stage III at the time of the assessment, not unstageable. C. Review of Resident #27's orders dated 02/2022 revealed to cleanse the right heel with normal saline, pat dry, and apply a foam dressing. Observation of Resident #27 right heel on 03/02/22 at 10:00 A.M., with the facilities wound nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 10 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 practitioner (WNP) #4 and facility Registered Nurse (RN)#99 revealed the resident had a Kerlix dressing intact to right heel dated 03/01/22. The WNP cut the kerlix off the right heel and the resident had an abdominal pad with a small amount of seriousangous drainage. There was no evidence of a foam dressing per the resident current orders. The WNP confirmed there was no foam dressing. The resident's wound was a deep tissue injury upon admission measuring 5.5 by 4.0 by 0.1 per the WNP. Last week the pressure ulcer was a stage III measuring 1.6 cm by 2.2 cm by 0.1 cm. Today the wound measured 1.6 cm by 1.5 cm which improved in size, however the issue had deteriorating and the pressure ulcer was now unstageable with 80% slough and 20 % granulation in the wound bed. New orders were received to cleanse with normal saline, apply Santyl (debris agent), and pad and protect. May use current order for 24 hours until Santyl is available. Review of the facility policy titled, Wound Care, dated 11/13/20 and revised June 2006, revealed wounds would be gridded every seven days, unless contraindicated. Wound documentation should include, but not be limited to wound bed description, granulation, type and description of drainage, and odor. Intervention would be put into place for those with actual skin breakdown and those at high risk for breakdown, as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 11 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure Resident #11 received foods and liquids at the appropriate texture per dietary orders. This affected one resident (Resident #11) of five residents reviewed. Findings include: Review of the medical record for Resident #11 revealed an admission date of 11/16/18 with diagnoses including dysphagia, mild cognitive impairment, dementia without behavioral disturbance, and altered mental status. Review of the physician's orders for February 2022 revealed orders for a low concentrated sweets and no added salt diet with mechanical soft level eight texture and nectar thick liquids. Review of the speech therapy progress note dated 02/21/22 at 2:22 P.M. revealed Resident #11 was at high risk of aspiration for thin liquids and recommendations included mechanical soft texture and nectar thickened liquids. Review of the nutrition care plan revised on 02/08/22, revealed Resident #11 was at nutritional risk due to decreased variable meal intakes and interventions included mechanical soft level eight texture and nectar thick liquids. Review of the facility's diet definitions revealed a mechanical soft level eight diet included very tender ground meats. On 02/28/22 at 10:27 A.M., interview with Resident #11 revealed the resident had difficulty swallowing and was receiving speech therapy services. On 02/28/22 at 11:10 A.M., observation of the lunch meal revealed Resident #11 had ice in one of his nectar thickened beverages, confirmed by Licensed Practical Nurse (LPN) #35 at the time of observation. On 02/28/22 at 11:37 A.M., interview with Dietary Supervisor #100 revealed the facility does not provide thickened liquid ice cubes. On 03/01/22 at 11:07 A.M., observation of the lunch meal revealed Resident #11 received regular texture meats in the jambalaya entree, confirmed by State Tested Nurse Aide (STNA) #121 at the time of observation. On 03/01/22 at 2:02 P.M., interview with Dietary Supervisor #100 verified residents with mechanical soft diets received regular texture jambalaya with the meats cut up into smaller pieces. He confirmed no ground meat jambalaya was prepared or served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 12 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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, review of an invoice, and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent contamination of food. This had the potential to affect all 85 residents. Findings include: 1. On 02/28/22 at 7:55 A.M., the filter on the back of the sandwich refrigeration cart was covered with dust. The observation was confirmed by Dietary Aide #124 at that time. 2. On 02/28/22 at 7:57 A.M., observations in the kitchen revealed the vents and pipes above the cooking area (stove and griddle) were dusty with a grease buildup. The observation was verified by Dietary Aide #124 at that time. On 03/01/22 at 11:07 A.M., the ansul (fire suppression system) pipes above the cooktop remained dusty and there was a build up of grease on the vents above the cooktop. A thick brown layer of grease was noticed on the side of the griddle by the fryer. All observations were verified with Dietary Supervisor #100 at that time. Dietary Supervisor #100 verified the area needed cleaned. At 11:10 A.M., Dietary Supervisor #100 stated the facility had an outside company that deep cleaned the hood twice a year and kitchen staff cleaned as necessary between those visits on an as necessary basis. Upon request, Dietary Supervisor #100 provided an invoice dated 11/30/21 and indicated it was the most recent visit by the outside company. The invoice indicated the kitchen exhaust and main hood were cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 13 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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** 3. Observation of Resident #37's room revealed an isolation cart was outside the door. Signs on the door included to see the nurse before entering, donning and doffing sign, a visitor sign in sheet for resident with suspected or confirmed coronavirus and a contact isolation sign. Residents Affected - Many Interview on 02/28/22 at 10:11 A.M. with RN #89 revealed the facility was in outbreak status. Residents such as Resident #37 who are not vaccinated or fully vaccinated are placed in quarantine during outbreak status. Observation on 02/28/22 at 11:47 A.M. of Resident #37's room revealed staff came to door. Licensed Practical Nurse (LPN) #46 asked State Tested Nurse Aide (STNA) #171 if she had to gown up. STNA #171 said yes. LPN #46 had a N-95 mask on, shield, gown, and gloves. STNA #171 donned the same personal protective equipment and pushed a hoyer lift in the room. To exit the room the hoyer lift was pushed to the door and cleansed the hoyer with several microdot minute wipes. They took off their gloves, gown, and N-95 mask. They changed their N-95. They did not change or clean their shield and goggles. RN #149 gowned, gloved and took in the residents' lunch. The nurse had goggles and a N-95 mask on. After delivering the tray, she removed her gloves, gown, N95 and put on new N-95. She did not clean goggles her goggles. Interview on 02/28/22 at 12:08 P.M. with RN #149 and LPN #46 verified they did not clean their goggles or shield when exiting the quarantine room. When asked they did not know what the policy was related to cleaning their shield and goggles. The door sign said when doffing they were to discard the shield/goggles or place in a receptacle to clean. Review of the facility policy titled, Coronavirus: Suspected or Confirmed, revised 02/09/22, revealed residents who are not up to date with all recommended COVID-19 vaccine doses (COVID-19 vaccine series plus booster) should be quarantined during during an outbreak. Personal protective equipment includes eye protection that covers both the front and sides of the face required if our county has a substantial or high community transmission rating. Remove before leaving the resident's room and clean from inside to outside and allow to dry. Based on record reviews, observation, interviews, and policy review, the facility failed to ensure goggles were sanitized upon exiting Resident #37's room, who was under droplet isolation precautions, and failed to ensure proper signage was displayed prior to entering Resident #21 and Resident #133 rooms who were reported to be on isolation precautions. This affected three residents (Resident #21, Resident #37, and Resident #133) with the potential to affect all 85 residents in the facility. Findings include: 1. Medical record review revealed Resident #21's was admitted to the facility on [DATE] with diagnoses including type two diabetes, weakness, adult failure to thrive, hypertension, heart failure, and elevated white count. Review of Resident #21's orders dated 02/03/22 revealed the resident was quarantined for possible COVID-19 exposure. There was no evidence of the type of isolation. Review of Resident #21's COVID-19 vaccine sheet dated 02/07/22 revealed the resident had one dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 14 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 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 of the Moderna vaccine on 02/09/22. Level of Harm - Minimal harm or potential for actual harm On 02/28/22 at 9:13 A.M., observation of Resident #21's room revealed no evidence of signage to indicate the resident was under quarantine precautions. Residents Affected - Many Interview on 02/28/22 at 9:13 A.M. and 03/02/22 at 8:26 A.M., with Licensed Practical Nurse (LPN) #154 confirmed the resident's room was not marked with signage to indicate the resident was on isolation or the type of isolation. The LPN reported the resident was on isolation because she was not completely vaccinated. The LPN reported the facility would also change the residents' orders to indicate she was on droplet isolation for non-vaccination. Interview on 02/28/22 at 10:11 A.M. with RN #89 revealed the facility was in outbreak status, (twice a week testing of staff and residents, isolation and quarantine due to COVID positive staff and/or resident). Residents who are not vaccinated or fully vaccinated are placed in quarantine (A quarantine is a restriction on the movement of people, animals and goods which is intended to prevent the spread of disease or pests) during outbreak status. Review of the facilities policy titled, Standard and Transmission-Based Precautions (TBPs), dated 05/05/20 and revised 02/24/22, revealed the facility would follow standard and TBP to prevent healthcare -associated infections and transmission of communicable disease to residents, staff, and visitors. For residents with an undiagnosed respiratory infection staff would follow standard contact and droplet precautions. Review of the facility policy titled, Coronavirus: Suspected or Confirmed, revised 02/09/22, revealed residents who are not up to date with all recommended COVID-19 vaccine doses (COVID-19 vaccine series plus booster) should be quarantined during during an outbreak. 2. Medical record review revealed Resident #133 was admitted on [DATE] with diagnoses including acute kidney failure, dementia, and heart failure. Review of Resident #133 February 2022 physician orders revealed an order for strict droplet isolation due to the resident not being up to date with COVID-19 vaccination series. Interview 02/28/22 at 10:11 A.M. with RN #89 revealed the facility was in outbreak status. Residents who are not vaccinated or fully vaccinated are placed in quarantine during outbreak status. Observation on 02/28/22 at 10:45 A.M. of Resident #133 revealed no indication the resident was under isolation precautions. Interview on 02/28/22 at 10:45 A.M. with RN #56 revealed Resident #133 was in droplet isolation due to not being vaccinated against COVID-19. She confirmed the resident did not have a sign indicating she was under isolation precautions. Review of the facilities policy titled, Standard and Transmission-Based Precautions (TBPs), dated 05/05/20 and revised 02/24/22, revealed the facility would follow standard and TBP to prevent healthcare -associated infections and transmission of communicable disease to residents, staff, and visitors. For residents with an undiagnosed respiratory infection staff would follow standard contact and droplet precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 15 of 16 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 366200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Bolivar 300 Yant Street, NW Bolivar, OH 44612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Coronavirus: Suspected or Confirmed, revised 02/09/22, revealed residents who are not up to date with all recommended COVID-19 vaccine doses (COVID-19 vaccine series plus booster) should be quarantined during during an outbreak. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366200 If continuation sheet Page 16 of 16