Inspection·March 31, 2022

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. Based on resident record review and staff interview, the facility failed to ensure a resident's code status documented in the electronic health record (EHR) matched the hard paper chart. This affected one (#11) of 16 resident reviewed for accuracy of the code status. The census was 32. Findings include: Review of Resident #11's medical record revealed an admission date of 04/12/21, with diagnoses including: hypertension, muscle weakness, and chronic obstructive pulmonary disease. Review of the paper document titled DNR Order Form signature date 10/18/21, revealed Resident #11's code status was do not resuscitate (DNR) comfort care (CC). Review of the electronic health record (EHR) for Resident #11 revealed the resident's code status was documented as full code. Interview on 03/29/22 at 2:07 P.M., with the Director of Nursing (DON) verified the EHR code status for Resident #11 was full code and the hard chart was DNRCC. The DON verified the code status documented in the EHR and hard chart did no match. 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 03/31/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, record reviews, family member and staff interviews, review of policy, the facility failed to maintain a clean homelike environment. This affected two (#5 and #11) of two residents reviewed for homelike environment. Facility census was 32. Findings include 1. Review of Resident #5's medical record revealed an admission date of 07/07/19, with diagnoses including: fracture of left femur, dementia with behaviors, hip replacement, muscle weakness, heart failure, kidney disease, chronic pain, and depression. Observation on 03/28/22 at 9:57 A.M., revealed Resident #5's bathroom was dirty. The toilet seat was observed with a dark colored substance smeared on the toilet seat. The toilet bowl had a splattered black mold- like substance on it. Interview on 03/28/22 at 2:25 P.M., with Resident #5's family member revealed concerns about the cleanliness of resident's bathroom. Observations on 03/29/22 at 9:40 A.M. and 3:00 P.M., revealed the resident's toilet remained dirty with the mold-like splattering inside the toilet bowel and a smeared substance on the toilet seat. Observation 03/30/22 at 10:52 A.M., revealed the resident's toilet seat and toilet bowl were dirty with a smear on the seat and a mold-like substance in the bowl. Observation on 03/30/22 at 12:03 P.M., revealed the housekeeping staff and a trainee went into resident's room for cleaning. The staff had entered the bathroom and mopped the floor of the bedroom. Housekeeping staff finished cleaning at 12:09 P.M. Observation on 03/03/22 at 12:12 P.M., revealed the resident's bathroom was not thoroughly cleaned. Resident #5's toilet still had a dark substance smeared on the toilet seat and a mold-like substance in the toilet bowl. Interview on 03/03/22 at 12:20 P.M., with Housekeeper #96 stated he did not use the brush, only sprayed a cleaning solution into the bowl and the staff member working with her was in training. Housekeeper #96 confirmed the appearance of the toilet. 2. Review of Resident #11's medical record revealed an admission date of 04/12/21, with diagnoses including: encephalopathy, fracture of the left femur, fluid overload, generalized weakness, syncope, anxiety and depression. Observation 03/28/22 at 8:39 A.M., revealed Resident #11's room had food on the carpeting under and around bed. Observation 03/29/22 at 9:43 A.M. and 3:05 P.M., revealed Resident #11's room had large and small crumbs and chunks of food covering resident's carpet. Interview on 03/29/22 at 4:00 P.M., with the Director of Environmental Services (DES) #105 revealed (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 03/31/2022 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 0584 housekeeping and laundry services are completed by four staff that typically work six to eight-hour shifts. Level of Harm - Minimal harm or potential for actual harm Review of the housekeeping and laundry staff schedule revealed one of the four staff was not listed as having any shifts. The schedule contained several days with either a housekeeper or laundry staff and some days facility did not have both scheduled. Residents Affected - Few Observation on 03/30/22 at 10:46 A.M., of housekeeping staff observed vacuuming the hallway outside of Resident #11's room. At 10:49 A.M., large crumbs of food were observed under resident's bed were observed. Interview on 03/30/22 at 11:10 A.M., with Housekeeper #96 revealed facility has been short staffed for laundry and housekeeping services. She revealed resident rooms should be cleaned daily including floors and bathrooms even for residents that do not use their bathrooms. Housekeeper #96 revealed they have finished cleaning all rooms in Resident #11's hallway. Interview on 03/30/22 at 11:16 A.M., with Register Nurse (RN) #73 revealed housekeeping staffing has been low lately. Interview on 03/03/22 at 12:20 P.M., with Housekeeper #96 confirmed the large crumbs under Resident #11's bed. She revealed she will need to get a hose vacuum to clean that area after confirming she had completed cleaning that entire hallway. Review of the policy titled Housekeeping Procedures, dated 02/19/07, revealed the resident rooms are to be swept and cleaned under furniture every two weeks, carpeted floor should be vacuumed every day. The policy also states resident bathroom floor are to be mopped daily and toilets should be cleaned daily from top to bottom and inside the bowl and also clean both sides of the toilet seat every day. 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 03/31/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to provide assistance with activities of daily living (ADL) care to dependent residents. This affected two (#5 and #10) of two residents reviewed for assistance with ADL care. Facility census was 32. Residents Affected - Few Findings include 1. Review of Resident #5's medical record revealed an admission date of 07/07/19, with diagnoses including: fracture of left femur, dementia with behaviors, hip replacement, muscle weakness, heart failure, kidney disease, chronic pain, and depression. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had significant cognitive impairment and required extensive assistance of one to two staff members for transfers and mobility and was totally dependent for transfers, and extensive assist of one staff for personal hygiene. Review of shower sheets for Resident #5 revealed showers were provided on 03/19/22, 03/26/22, and 03/29/22. No other shower sheets were available for the entirety of March 2022. Review of bathing documentation for Resident #5 from March 2022 revealed no baths were documented. All baths were marked as activity did not occur. Interview on 03/31/22 at 10:10 A.M., with Licensed Practical Nurse (LPN) #61 revealed the facility had two nurses and 3 State Tested Nurse Aide (STNA) 's scheduled. LPN #61 revealed the facility was trying to get a consistent shower aide as showers had been getting missed. LPN #61 revealed recently residents have been given bed baths instead of showers due to staffing. LPN #61 revealed facility staff complete paper shower sheets which are entered in a shower binder. LPN #61 confirmed several sheets were missing or unaccounted for but could not confirm if the showers had been given. Interview on 03/31/22 at 10:18 A.M., with STNA #58 revealed the section in the Activities of Daily Living (ADL) documentation labeled hygiene would include brushing teeth, brushing hair, and wiping their under arms and the bathing section includes tub baths and bed baths. Interview on 03/31/22 at 10:29 A.M., with STNA #132 revealed Resident #5 missed several showers earlier in the month of March and her and another STNA noticed Resident #5 looked dirty and unkempt and her hair was looking bad. So the STNA gave resident a bath on Saturday 03/19/22, which was not her shower day. Resident revealed the facility used to have a bath aide which helped get all the baths done timely, but they no longer have this position consistently filled. 2. Review of Resident #10's medical record revealed an admission date of 01/06/21, with diagnoses including: muscle weakness, hypo-osmolality, weakness, difficulty in walking, lack of coordination, syncope, dementia with behaviors, diabetes type two, and sepsis. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required limited assistance of one staff member for transfers and extensive assist of one staff for personal hygiene. (continued on next page) 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 03/31/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care revealed Resident #19 had an ADL self-care deficit with interventions to allow sufficient time for care, encourage resident to participate to the best of her abilities, and monitor for changes in grooming abilities. Review of ADL documentation for Resident #10 from March 2022 revealed hygiene was documented almost daily. Shaving and nail care were not specifically documented. Observation on 03/28/22 at 10:11 A.M., of Resident #10 revealed she had several inches long whiskers on her lip and chin. Interview on 03/28/22 at 10:11 A.M., with Resident #10 revealed staff help her with grooming including shaving and trimming of her nails. Observation on 03/29/22 at 12:10 P.M., of Resident #10 revealed she still had long whiskers on her lip and chin and her nails were long and had not been cut for some time. Interview on 03/29/22 at 12:10 P.M., with Resident #10 revealed she preferred her nails to be short. Resident #10 revealed she has asked staff to trim her nails and they say they will come back and never do. Resident #10 revealed the famous saying here was I forgot. Staff would tell her they will return and when she asked staff why they never returned for care they said, I forgot. Observation on 03/30/22 at 10:55 A.M., of Resident #10 revealed several long facial hairs and long fingernails. Interview at the observation revealed Resident #10 stated the facility staff are supposed to cut her nails and they are much longer than she likes. Interview on 03/30/22 at 11:16 A.M., with Registered Nurse (RN) #73 revealed facility staffing has improved in recent weeks and she feels that all care can get done but some days are better than others. RN #73 stated each hall today has one nurse and two STNA's scheduled which is very manageable. RN #73 revealed she has heard residents make complaints about staffing especially in the STNA role and revealed they had been behind on showers and ADL care. RN #73 revealed that shaving and nail care should be done on shower days. Observation on 03/31/22 at 9:40 A.M., revealed Resident #10 continued to have long facial hairs and long nails. Interview on 03/31/22 at 10:10 A.M., with LPN #61 revealed not previously noticing Resident #10's long nails but had noticed long hairs on her chin. LPN #61 revealed being unsure if aides had offered to assist Resident #10 with this care but denied he has offered to assist the resident with this care. Interview on 03/31/22 at 10:18 A.M., with STNA #58 revealed the section in the ADL documentation labeled hygiene would include brushing teeth, brushing hair, and wiping their under arms. STNA denied this would include shaving and nail care as those have their own sections for documentation. STNA #58 revealed she was not familiar with Resident #10's grooming needs as she had baths scheduled on third shift and staff are responsible to complete these tasks during bathing times. Interview on 03/31/22 at 10:29 A.M., with STNA #132 revealed she noticed Resident #10's long nails, but revealed it was third shifts responsibility to trim them. (continued on next page) 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 03/31/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Promoting and Maintaining Resident Dignity, dated 12/2020, revealed the facility was responsible to protect and promote resident quality of life. The policy revealed all staff members are involved in providing care to promote and maintain resident dignity and when interacting with a resident, pay attention to the resident as an individual. Respond to requests in a timely manner. Groom and dress the resident according to their preferences. Residents Affected - Few This deficiency substantiates Complaint Number OH00110940. 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 03/31/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, Registered Dietician and staff interviews, and policy review, the facility failed to ensure a resident's weight was monitored. This affected one (#24) of two resident reviewed for nutrition. The census was 32. Residents Affected - Few Findings include: Review of Resident #24's closed medical record revealed an admission date of 02/26/22, with diagnoses including: metabolic encephalopathy, hypertension, heart failure, and Alzheimer's disease. The resident was discharge home on [DATE]. Review of a dietary risk assessment dated [DATE], revealed Resident #24's dietary risk was moderate. Review of a dietary progress note dated 03/04/22, revealed Resident #24's weight was 147.1 pounds per the hospital record dated 02/21/22. The goal was for the resident's weight to remain stable with no significant weight changes related to current body mass index (BMI) of 23 (normal). Documentation revealed the goal included weight management, hydration management, and prevention of skin impairment. A recommendation was for magic cup twice a day in between meals. Further review of the medical record revealed no other weights being obtained at the facility for Resident #24. Review of a care plan dated 03/04/22, revealed Resident #24 had nutritional problems or potential nutritional problems related to metabolic encephalopathy, heart failure, hyperlipidemia, and Alzheimer's disease. Goals included weight will be stable with no significant weight changes in 30, 90, and 180 days. Interventions include magic cup two times a day and monitor and evaluate weights as needed and monthly. Interview on 03/29/22 at 11:45 A.M., with the Director of Nursing (DON) verified the medical record for Resident #24 contained no evidence of the resident's weight being obtained while the resident was at the facility. Interview on 03/29/22 at 2:26 P.M., with the Registered Dietician (RD) #100 revealed the dietician would expect a resident's weight to be obtained within the first 24 hours after admission. RD #100 further reported newly admitted residents were to be weighed weekly for four weeks and then monthly. RD #100 verified the medical record for Resident #24 had no evidence of the resident being weighed by the facility. RD #100 reported the only weight documented in the resident medical record was a weight obtained prior to admission, while the patient was at the hospital. Review of a policy titled, Weight Monitoring dated October 2020, revealed a weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule will be developed upon admission for all residents. Weights should be recorded at the time obtained. The policy revealed newly admitted residents - monitor weight weekly for four weeks. 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 03/31/2022 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, policy review, interviews with staff and the Medical Director, the facility failed to provide evidence pharmacy recommendations were reviewed by the physician and acted upon in a timely manner. The affected one (#4) of five resident reviewed for medications. The facility census was 32. Findings include: Review of Resident #4's medical record revealed an admission date of 09/09/10, with diagnoses including weakness, osteoarthritis, dysphasia, orthopedic aftercare, anxiety, chest pain, cognitive impairment, major depressive disorder, arthropathy, back pain, hypertension, gout, and dementia with behaviors. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment and required extensive assistance of one to two staff members for transfers and ambulation. Review of the pharmacy recommendations revealed the pharmacist made two recommendations to the physician on 01/13/22 (to initiate Senna 8.6 milligrams (mg) 2 tablets, once daily at bedtime while resident was prescribed Morphine Sulfate, and to attempt a gradual dose reduction to Trazadone from 50 mg to 25 mg once daily). One recommendation to the physician on 02/10/22 (consider avoiding use of Morphine Sulfate 15 mg twice daily in combination with Clonazepam 0.5 mg, due to concern for this combination to have increased side effects). And one recommendations to the physician on 03/01/22 (a repeat recommendation from the 01/13/21 to start Senna 8.6 mg with Morphine Sulfate). Review of the Medication Administration Record (MAR) for January 2022, February 2022, and March 2022 revealed no changes to physician orders based on the pharmacy recommendations. Interview on 03/30/22 at at 9:50 A.M., with Director of Nursing (DON) revealed the pharmacy recommendations and physician responses could not be located and were requested to be sent over by the pharmacy. Interview on 03/31/22 at 11:21 A.M., with the facility Medical Director (MD) #130 revealed the facility typically places pharmacy recommendations on his desk for weekly review. He revealed after he reviews and signs the pharmacy recommendations, he is unsure of what happens to the paperwork and how it is filed. MD #130 verified facility does not have a record of him reviewing the recommendations and signing off on the forms. Review of the policy titled LTC Facility's Pharmacy Services and Procedure: Medical Regimen Review (MRR), dated November 2016, revealed the physician receiving the MRR should act upon the recommendations contained in the MRR. The policy revealed the facility shall maintain copies of the MRR's on file as part of the permanent health record. 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 03/31/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and staff interview, the facility failed to ensure medication was administered as ordered by the physician, with a medication error rate less than five percent (%). There was four medications errors out of 32 opportunities to result in a medication error rate of 12.5 %. This affected one (#2) of three residents observed for medication administration. The census was 34. Residents Affected - Few Findings include: Observation of medication administration on 03/29/22 at 8:06 A.M., with Registered Nurse (RN) #73 revealed RN #73 was preparing medication to be administered to Resident #2. RN #73 gathered the resident medication for administration: one bottle of artificial tears eye drops artificial tears, senna 8.6 milligram tablet, amiodarone 100 mg tablet, centrum silver tablet, eliquis 5 mg tablet, tamsulosin hydrochloride 0.4 mg tablet, lidocaine 4% topical patch, and alaway eye drop 0.025%. Continued observation revealed the RN #73 gathered the medication and brought the medication to the room of Resident #2. RN #73 washed hands, donned gloves and administered the artificial tears one drop in each eye. Then RN #73 administered the oral medication. RN #73 informed Resident #2 the alaway eye drops needed to be administered about 15 minutes after the artificial tears. RN #73 then asked Resident #2 to lean forward so the lidocaine patch could be placed on the residents back. The resident leaned forward the nurse removed a lidocaine patch from the resident back and placed the new lidocaine patch on the resident. Continued observation revealed RN #73 left the resident's room and returned in approximately 10 minutes. Further observation revealed RN #73 returned to the resident's room and administered the alaway eye drops one drop in each eye. Adequate infection control practices were maintained during the alaway eye drop administration. Review of Resident #2's active medication orders revealed the medication scheduled for administration at 7:30 A.M. was artificial tears (ophthalmic lubricant) two drops in each eye. The medication scheduled for administration at 8:00 A.M. was senna (laxative) tablet 8.6 mg. The medication scheduled for 9:00 A.M. was eliquis (anticoagulant) 5 mg tablet, centrum silver (supplement) one tablet, amiodarone (antidysrhythmic) 100 mg tablet, and alaway (antihistamine) 0.025% one drop each eye. Medication scheduled for administration at 10:00 A.M. were tamsulosin hydrochloride (alpha blocker) 0.4 mg tablet and lidocaine pain relief adhesive patch 4%. Review of the physician order for the lidocaine revealed the patch was to be removed at bedtime. Interview on 03/29/22 at 10:08 A.M., with RN #73 verified the artificial tears eye drop was ordered for two drops in each eye and RN #73 administered one drop in each eye. Continued interview with RN #73 verified the medication lidocaine patch and tamsulosin hydrochloride were scheduled to be administered at 10:00 A.M. but were administered early at 8:06 A.M. RN #73 further verified the lidocaine patch that was placed on Resident #2's back on 03/28/22 was removed by this nurse prior to placing the new lidocaine patch. The nurse verified the lidocaine patch was suppose to be removed on 03/28/22 at bedtime. 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 03/31/2022 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, record review, resident and staff interviews, the facility failed to ensure a resident with a food allergy was not served food related to the allergy. This affected one (#331) of 32 residents observed for dining. Facility census was 32. Findings include Review of Resident #331's medical record revealed an admission date of 03/25/22, with diagnoses including: sepsis, muscle weakness, heart failure, type two diabetes, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease. Review of Resident #331's medical chart, revealed onions were a listed allergy. Observation 03/28/22 at 12:12 P.M., revealed Resident #331's tray was returned to the kitchen. State Tested Nurse Aide (STNA) #58 informed kitchen staff working resident had an allergy to onions and was served onion rings. Interview on 03/28/22 at 12:15 P.M., with STNA #58 revealed resident did not want onions when she brought his tray so she went to get him an alternative. Interview on 03/28/22 at 12:42 P.M., with Resident #331 revealed STNA #58 brought his tray for lunch which contained a side of onion rings on it. He informed STNA #58 he is allergic to onion rings and she looked at his ticket which stated he is allergic to onion rings. Resident #331 reveled STNA #58 was apologetic and exchanged his tray for a different side dish. Interview on 03/29/22 at 10:15 A.M., with Dietary Manager #88 revealed when a resident admits, the nurse will inform the kitchen of the dietary orders and allergies. DM #88 revealed she meets with residents upon admission to discuss food preferences and dietary needs. DM #88 revealed there was an issue with Resident #331 getting food he was allergic to due to a new kitchen staff member failing to read the tickets when making up the trays. DM #88 revealed she first met with resident on 03/28/22 after the lunch meal. 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 03/31/2022 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 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 observations, staff interviews,and policy review, the facility failed to safely store food in the dry storage, refrigerator, freezer and failed to sanitize kitchen equipment. This affected 31 of 31 residents who receive food from the kitchen, excluding Resident #6 who does not eat food from the kitchen. The facility census was 32. Findings include Observation on 03/28/22 from 9:20 to 9:30 A.M., with Dietary Manager (DM) #88 revealed noodles in dry storage were tied but were undated. Four large cans of cream corn had large fist sized dents and had been placed on the shelf for use. A large bag of cauliflower had a baseball sized hole and was left open to air with piece falling out of the bag. A bag of frozen chicken was undated and had been freezer burnt. The refrigerator had a container of unsealed and undated cinnamon rolls and a second container that was unopened and undated. Interview on 03/28/22 from 9:20 to 9:30 A.M., with Dietary Manager (DM) #88 confirmed the observations listed above. DM #88 stated when the can comes from the supplied dented they will return it, but if it is dented by facility staff, it will be wiped off and stored on the shelf for use. Observation on 03/30/22 at 10:15 A.M., revealed no cans in the dry storage room had a date marked regarding the day of arrival to the facility. A small freezer in the dry storage room filled with bread revealed no dates were found on the bread either from delivery or from expiration date. An unopened box of muffins was in the fridge with no date on it and a second box of muffins was unopened with a date of 01/30/22. The cinnamon roll container seen on 03/28/22 in the refrigerator had been placed back in the fridge. Interview on 03/30/22 at 10:15 A.M., with Covering Kitchen Manager (CKM) #123 revealed the facility should be dating every item that arrives to the facility according to the policy. CKM #123 confirmed the findings from the 03/30/22 observations. CKM #123 revealed food can be kept in the freezer for up to one year and food should be kept in refrigerator for only 1 week after opening or until expiration for items such as milk. CKM #123 confirmed a box of muffins was in the fridge and had no date and another box of muffins was in the fridge with the date 01/30/22. CKM #123 pulled out the muffins to be thrown away. Observation on 03/29/22 at 11:55 A.M., of food temperatures revealed the facility did not sanitize the food thermometer when taking holding food temperatures between each item. Dietary Manager (DM) #88 took the temperature of the peas, then wiped the thermometer off with a dry paper towel. DM #88 then took temperature of the tomato soup and wiped the thermometer off with the same paper towel. DM #88 then took temperature of the grill cheese sandwich and attempted to wipe it off with the same paper towel. The cheese was not coming off, so DM #88 ran it under water and used a wet rag to clean the cheese off the thermometer. Interview on 03/29/22 at 12:02 P.M., revealed the kitchen did not currently have any sanitation wipes to clean the thermometer. DM revealed she puts the thermometer through the dishwasher after each meal. Review of the policy titled Food Temperature Requirements, dated 04/02/19, revealed the policy does (continued on next page) 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 03/31/2022 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 not specify how the thermometer should be cleaned. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Receiving and Storage, dated 04/02/19, revealed the policy revealed items will be properly stored to maintain food safety and quality. The policy revealed all items should be dated when received to ensure correct product rotation. The policy revealed swollen, rusted and dented cans will be returned to the provider for credit. The policy revealed all food items will be covered labeled and dated in storage after opening and using a portion, removing from the case and when transferring to another container. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 13 of 13