Health inspection·February 27, 2020

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of an incident report and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) Assessment for a resident. This affected one (#12) of thirteen residents reviewed during Phase II of the survey. Facility census was 38. Residents Affected - Few Findings include: Review of the clinical record revealed Resident #12 was admitted [DATE]. Diagnoses include chronic obstructive pulmonary disorder, hypertension, hyperlipidemia, Stage III chronic kidney disease, and history of stroke with dysphagia. Resident #12 was admitted with hospice services and has received these services since admission. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was unable to participate in the Brief Interview for Mental Status (BIMS). Resident #12 received hospice services. Resident #12 also had a history of falls since the previous assessment. Resident had one fall without injury and one fall with injury (except major injury). Further review of the annual MDS assessment dated [DATE] revealed the resident required extensive assist with bed mobility, dressing, toileting, and personal hygiene. The resident required total assistance with transfers and bathing. Review of MDS Annual assessment dated [DATE] revealed section J100 revealed Resident #12 had a fall with major injury since prior assessment. Further review of the annual MDS revealed the resident was not coded for receiving hospice services. Review of progress note dated 11/22/19 at 11:19 A.M. revealed the resident continued on fall follow-up with no new or apparent injuries. Review of incident report dated 11/25/19 revealed the resident had a fall with major injury to the left knee. Interview 02/24/20 at 1:37 P.M., MDS Nurse #39 verified Resident #12 had received Hospice services since admission and the MDS assessments dated 01/07/20 was inaccurately coded. Interview 02/25/20 at 11:05 A.M., MDS Nurse #39 stated Resident #12 acquired a skin tear to his left knee after a fall 11/21/19. She confirmed the MDS assessment dated [DATE] was inaccurately coded due to a documentation error she failed to catch when it populated from the incident report to the MDS Assessment. MDS Nurse #39 confirmed Resident #12's fall was without major injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 2 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident, family and staff interview, the facility failed to timely identify and treat a resident's urinary tract infection (UTI). This affected one (#129) of three residents reviewed for urinary tract infections. Facility census was 38. Findings include: Review of Resident #129's medical record revealed an admission date of 02/19/20 with diagnoses including post femur fracture, hypertension and hyponatremia. Review of Resident #129's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was not completed. The MDS revealed the resident required one-person physical assist for bed mobility, toilet use and personal hygiene. Review of Resident #129's Plan of Care dated 02/19/20 revealed resident had a self-care deficit related to history of open reduction of femur fracture. Review of Resident #129's nursing progress notes dated 02/21/20 revealed the resident complained of urinary frequency. Review of Resident #129's physician order dated 02/21/20 revealed an order to obtain urinalysis, culture and sensitivity. The order additionally documented the urinalysis may be obtained on 02/24/20. Review of Resident #129's Certified Nurse Practitioner Registered Nurse (RN) #200 progress note dated 02/24/20 revealed resident and daughter asking for results from urinalysis. The RN #200 revealed the results had not yet been received. Review of Resident #129's urinalysis report dated 02/24/20 at 1:48 P.M. revealed a partial report status which included abnormal clarity, blood noted in urine, leukocytes, white blood cells, epithelial cells and bacteria. The lab report identified the specimen was collected on 02/24/20 and received by the lab on 02/24/20. Interview on 02/24/20 at 11:30 A.M. with Resident #129 and Resident #129's daughter revealed the resident provided a urine sample on 02/21/20. Resident #129's daughter stated she spoke to the Certified Nurse Practitioner Registered Nurse (RN) #200 and asked about the results of a urinalysis. Resident #129's daughter revealed the RN #200 stated the results had not yet been received. Interview on 02/26/20 at 10:44 A.M. with Resident #129 and Resident #129's daughter revealed the resident continued to have urinary urgency. Resident #129 also complained of back pain. The resident confirmed the facility had not yet addressed the urinary symptoms. Interview on 02/26/20 at 12:30 P.M. with the Director of Nursing (DON) reviewed the order written on 02/21/20 and was not able to provide an explanation as to why the urine sample was not sent until 02/24/20. The DON called the laboratory and was told the pharmacy does not pick up specimens unless the order identified that it was a Stat or Immediate order. The DON revealed it was her expectation that the urine should be sent out right away for a resident who was symptomatic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 3 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Interview on 02/26/20 at 2:36 P.M. with RN #200 revealed she would not have written an order that would have waited three days to send a urine specimen on a resident who was having symptoms. The RN #200 stated the final lab report for the urinalysis had not yet been received by the facility. The RN #200 stated the urine sample should have been sent to lab on 02/21/20 when the resident first reported the symptoms. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 4 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to timely respond to pharmacy recommendations. This affected one (#2) of six residents reviewed. Facility census was 38. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include osteoarthritis, pain in joint, and hypertension. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively intact, had no hallucinations, delusions or behaviors coded. Resident is coded as requiring one person assist supervision for bed mobility, dressing, and personally hygiene, and is independent is toileting. Review of Resident #2's physician orders revealed the resident has the following orders: Calcium 600 plus Minerals (calcium Carbonate-Vitamin D3 minerals tablet 600 mg calcium- 400 units: Administer one tablet by mouth two times a day at 9:00 A.M. and 1:00 P.M. with an order date of 07/12/19; Iron (Feosol/Ferrous) tablet 325 milligrams (mg) (equal to 65 mg iron)-administer one tablet by mouth one time a day at 9:00 A.M. for supplement with an order date of 07/12/19. Review of medical record revealed the resident had a pharmacy recommendation written on 10/08/19 indicating the medication calcium with vitamin D mineral supplement and iron supplement are given concurrently. The recommendation was to consider minimizing this potential absorption-relate drug interaction by separating administration of these two products by at least two hours. Rationale for recommendation: concurrent administration of Calcium/Vitamin D/Mineral and iron products may reduce the absorption of either iron or the interacting medication. The recommendation is signed by Registered Nurse (RN) #45 indicating it was completed on 10/11/19. Further review of the medication administration record (MAR) revealed the resident currently has both medications administered at the same time of 9:00 A.M. Review of the physician orders revealed there was not order written indicating to change the administration time of either medications. During an interview with the Director of Nursing (DON) on 02/25/20 at 4:45 P.M. confirmed Resident #2's pharmacy recommendation from 10/08/19 was not acted upon and there was no evidence of change in the resident medication timing to indicate the facility had acted on the recommendation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 5 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and review of an insulin pen manufacture recommendations, the facility failed to prime an insulin pen prior to administering insulin resulting in a significant medication error. This affected one (#133) of one observed for insulin administration. The facility identified one (#133) resident who receives insulin through via insulin pen administration on the North hallway. Facility census was 38. Residents Affected - Few Findings include: Review of the medical record for resident #133 revealed an admission date of 2/14/20 with diagnosis that include but not limited to kidney failure, hypertension, diabetes, congestive heart failure, pain and hearing loss. Review of Resident #133's physician orders revealed the resident has an order for Admelog Solostar 100 units/ml sliding scale insulin that indicated if finger stick blood sugar (FSBS) is 240-289 administer three units of Admelog SoloStar 100u/ml. During an observation of the insulin administration for Resident #133 on 02/26/20 at 4:34 P.M. Licensed Practical Nurse (LPN) #60 was observed to perform Resident #133's FSBS as per standard/order with a reading of 273. LPN #60 was then dialed the resident dose of insulin via an Admelog insulin pen to three units and administered the insulin to the resident in the abdomen. The nurse was not observed to perform a safety test on the insulin pen prior to the administration of the insulin. During an interview with LPN #60 on 02/26/20 at 4:39 P.M. confirmed he/she administered three units of insulin to Resident #133 and prior to the administration did not perform any prior procedure to the insulin pen. LPN #60 stated to administer insulin with the pen you just dial the dose and administer the insulin. Review of the Admelog insulin manufacture recommendations revealed to always perform a safety test. The policy further instructed to always do a safety test before each injection to check your pen and the needle to make sure they are working properly. Make sure that you get the correct insulin dose. Select two units by turning the dose selector until the dose pointer is at the two mark. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly. If no insulin appears: You may need to repeat this step up to three times before seeing insulin. If no insulin comes out after the third time the needle may be blocked. If this happens: Change the needle, then repeat the safety test. Do not use the pen if there is still no insulin coming out of the needle tip. Use a new pen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 6 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of the Emergency Drug Kit content list and review of medication information from the Drug Enforcement Agency (DEA), the facility failed to observe a resident consume their medications. This affected one (#2) out of seven residents observed receiving medications at the facility. Additionally, the facility failed maintain a permanently-affixed Emergency Drug Kit containing Schedule II controlled substances that was being stored within the medication storage room. The facility census was 38. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include osteoarthritis, pain in joint, and hypertension. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively intact, had no hallucinations, delusions or behaviors coded. Resident is coded as requiring one person assist supervision for bed mobility, dressing, and personally hygiene, and is independent is toileting. Review of the resident physician orders for the resident revealed the resident has the following medications ordered at 9:00 A.M.: Ocular Vitamin tablet; Aspirin EC 81 milligrams (mg); Iron 325 mg; Calcium 600 vitamin D3 400 units; Cod liver oil 1,250-135 units administer two capsules; Glucosamine sulfate 500 mg; Lasix 40 mg give with Lasix 20 mg; Losartan 25 mg and Potassium Chloride 20 mg. Further review of the medical record revealed there was no physician order and/or no assessment permitting Resident #2 to self-administer medications. During an observation on 02/24/20 at 10:10 A.M. the medication cart was observed in the hallway between room [ROOM NUMBER] and 37 pushed up to the wall that on that side of the hallway. Registered Nurse (RN) #400 was observed exiting Resident #2's room and returned to the medication cart going to the far left side of the cart out of visual range of Resident #2 who remained in his/her room taking medication out of the medication cup and taking the medication. The resident was observed to take five medications during this time and still had medication in the cup to be administered. The nurse re-entered the resident room and proceeded to go into the bathroom remaining out of visual range of the resident who continued to take medication out of the pill cup and take the medications. The nurse exited the room again and moved her cart further down the hallway between room [ROOM NUMBER] and room [ROOM NUMBER], where the nurse could look into the room and keep the resident in visual sight if the nurse chose to do so. The nurse however proceeded to prepare medications for another resident, and not keep the resident in constant visual sight. During an interview with RN #400 on 02/24/20 at 10:55 A.M. confirmed the nurse gave Resident #2 her medication and then returned to her cart. RN #400 stated she did go back into the room and wash her hands in the bathroom. During an interview with the Resident #2 on 02/24/20 at 11:10 A.M. confirmed the nurse did not remain in the room this morning when his/her pills were given to him/her. Resident #2 stated some nurses stay in the room and some do not. Resident #2 stated the nurse gave me the pills and left the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 7 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few while she took the medication and my potassium pills. Resident #2 stated they break the potassium pills in half to help them go down easier and she always takes them with milk to help. During an interview with the Director of Nursing on 02/26/20 at 12:25 P.M. confirmed the expectation of the facility nurses is to have the resident in visual sight while the residents take the medications to ensure all medications are consumed. 2. Observation in medication room [ROOM NUMBER]/26/20 at 10:05 A.M. revealed the Emergency Drug Kit for narcotics were stored in a canvas bag with a red lock tag attached to the zipper. The bag was freestanding and was not permanently affixed to the counter. Review of the Emergency Drug Kit contents revealed the following medications and quantities were being stored in the Emergency Drug Kit: Medication Quantity -Acetaminophen/codeine 300 milligrams (mg)/30 mg Six -Alprazolam 0.25 mg Six -Alprazolam 0.5 mg Six -Clonazepam 0.5 mg Six -Diazepam 5.0 mg Six -Diazepam 2.0 mg Six -Fentanyl 25 micrograms (mcg)/hour patch Three -Fentanyl 50 mcg/hour patch Three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 8 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 0761 -Fentanyl 12 mcg/hour patch Level of Harm - Minimal harm or potential for actual harm Three -Hydrocodone/acetaminophen 7.5/325 mg Residents Affected - Few Six -Hydrocodone/acetaminophen 5/325 mg 12 -Hydrocodone/acetaminophen 10/325 mg Six -Hydromorphone 2.0 mg Six -Lorazepam 0.5 mg Six -Lorazepam 1.0 mg Six -Morphine Sulfate 15 mg Six -Morphine Sulfate 20 mg/1.0 solution Two -Morphine Sulfate ER 15 mg Six -Oxycodone HCL 5 mg Six -Oxycodone/acetaminophen 7.5/325 mg Six -Oxycodone/acetaminophen 10/325 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 9 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 0761 Six Level of Harm - Minimal harm or potential for actual harm -Oxycodone/acetaminophen 5/325 mg 12 Residents Affected - Few -Oxycontin ER 12 Hour 10 mg Six -Pregabalin 50 mg Six -Temazepam 7.5 Six -Tramadol 50 mg Six -Zolpidem 5 mg Six Interview 02/26/20 at 10:06 A.M. with Registered Nurse (RN) #13 verified the narcotics with the Emergency Drug Kit was unopened indicating no medication had been removed since delivery from the pharmacy and the box was not permanently affixed in the medication room. Review of the information from DEA website (https://www.dea.gov/drug-scheduling) revealed Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are: combination products with less than 15 milligrams of Hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), Fentanyl, Dexedrine, Adderall, and Ritalin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 10 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to store food safely. This had the potential to affect 38 of 38 residents who receive food from the kitchen. Facility census was 38. Residents Affected - Many Findings include: Observation 02/24/20 at 8:15 A.M. in dry storage revealed two boxes of Gold Medal Pancake Mix with an expiration date of 12/28/19 and three packages of Jet Puffed marshmallows with an expiration date of 01/18/19. Further observation revealed an opened, unlabeled container of chocolate fudge frosting. Interview 02/24/20 at 8:25 A.M. Dietary Manager verified items in dry storage were outdated and unlabeled. Observation 02/24/20 at 8:30 A.M. in walk-in refrigerator revealed one container of cottage cheese with an expiration date of 01/19/20, two containers of sour cream with an expiration date of 01/14/20, and unlabeled cheese slices wrapped in saran wrap. There was also an opened, undated bottle of water on its side on the shelf that leaked when set upright. Interview 02/24/20 at 8:40 A.M. Dietary Manager verified the outdated and unlabeled foods in the refrigerator. The facility confirmed the dietary concerns had the potential to affect all 38 residents who receive their meals and food from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 11 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, wound care observation, staff interview and policy review, the facility failed to perform hand hygiene during a dressing change for Resident #12. This affected one (#12) of three residents sampled for wound care. Facility census was 38. Residents Affected - Few Findings include: Review of the clinical record revealed Resident #12 was admitted [DATE]. Diagnoses include chronic obstructive pulmonary disorder, hypertension, hyperlipidemia, Stage III chronic kidney disease, and history of stroke with dysphagia. The resident required extensive assist with bed mobility, dressing, toileting, and personal hygiene. The resident required total assistance with transfers and bathing and had moderate cognitive impairment. Observation of wound care 02/26/20 01:55 PM, revealed Hospice Registered Nurse (RN) #250 did not perform hand hygiene between glove changes after removing soiled dressing from Resident #12's left mid-back and applying a clean dressing. During an interview 02/26/20 at 1:55 P.M., Hospice RN #250 confirmed she did not was her hands between glove changes during the dressing change for Resident #12's left mid-back. Review of infection control policy for wound care revised February 2014 under section titled Steps in Procedure revealed: put on clean gloves; loosen tape and remove soiled dressing; pull glove over dressing and discard into plastic or biohazard bag and wash and dry hands thoroughly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 12 of 13 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to offer a resident the Pneumococcal 23 vaccine. This affected one (#10) our of five residents reviewed for immunizations. Facility census was 38. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses that include but are not limited to atrial fibrillation, acute kidney failure and congestive failure. Review of the immunization record revealed there was no immunization consent in the the medical record, however the facility provided historical record that indicated the resident had the Prevnar 13 immunization on 10/26/17, there was no indication of the pneumococcal 23 being offered and/or administered. On 02/26/20 at 1:43 P.M. interview with Infection Control Designee/Registered Nurse #64 confirmed Resident #10 received the Prevnar 13 immunization on 10/26/17; however, there is no documentation regarding if the resident was no offered and/or received the Pneumococcal 23 immunization. Review of facility policy titled Pneumococcal Vaccine revised December 2012 revealed under Policy Interpretation and Implementation: 1. Upon admission, residents will be assessed for eligibility to receive the Pneumovax (pneumococcal vaccine) and Prevnar 13, and when indicated, arrangements will be made for vaccine administration. 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given within the past year or refused) per our facility's physician-approved pneumococcal vaccination protocol, which is as follows: For resident's who received Pneumovax vaccine prior to age [AGE], have never received the Pneumovax vaccine or are unsure as to what date the received the Pneumovax vaccine and this information cannot be obtained from the PCP; Prevnar 13 will be administered then the Pneumovax vaccine administered twelve months later. 8. Administration of the pneumococcal vaccine or revaccinations will be made in accordance with the current Center for Disease Control and Prevention (CDC) recommendations at the time of vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 13 of 13