Health inspection·December 19, 2019

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 record review and staff interview, the facility failed to provide an estimated cost for services for one (Resident #56) who was discharged from Medicare part A services and remained in the facility. The deficient practice affected one (Resident #56) of three residents reviewed for Beneficiary Notices. The facility census was 68. Residents Affected - Few Findings include: Review of the Beneficiary Notices for Resident #56 revealed the resident was discharged from Medicare part A services on 09/20/19 and remained in the facility. Review of the Advanced Beneficiary Notice of Non-Coverage (ABN) for Resident #56 showed the notice did not include an estimated cost of services following discharge from Medicare part A services. Interview with the Office Manager on 12/17/19 at 4:34 P.M. confirmed the ABN did not include any estimated costs for continued services. The Office Manager stated the training she received did not accurately inform her of how to complete the form. The Office Manager stated she thought only the estimated cost of the resident's room and board needed to be included on the notice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 2 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and policy review, the facility failed to provide an accurate smoking assessment with smoking materials secured safely for one (Resident #25) of one resident reviewed for safe smoking. The facility census was 68. Findings include: Resident #25 was admitted on [DATE] with diagnoses including dementia, major depression, anxiety and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment which was considered severely impaired cognition. Review of the smoking assessment dated [DATE] completed by Registered Nurse (RN) #127 revealed Resident #25 had cognitive loss, could light his own cigarettes, smoked two to five cigarettes daily, and the staff did not store his lighter and cigarettes. He was safe to smoke unsupervised outside in the enclosed shelter. Interview on 12/17/19 at 5:30 P.M. with Licensed Practical Nurse (LPN) #204 revealed Resident #25 kept his cigarettes/lighter in his room and never smoked in his room. Observation at that time with LPN #204 verified there were three packages of cigarettes and a lighter on the over bed table, unsecured and with no lock box available in Resident #25's room. Interview with RN #127 on 12/18/19 at 10:11 AM revealed when she assessed the resident on 10/07/19 she did not realize the lighter/cigarettes were unsecured in his room. RN #127 verified the smoking assessment did not identify the unsecured lighter and cigarettes. Review of the smoking policy dated 06/12 revealed the purpose was to provide a safe environment for all residents and proper assistance for those residents who smoked with five designated smoke times for resident who required smoking supervision. A smoking assessment for each smoker determined if a resident may retain cigarettes and lighter in their room. An alert and oriented resident who understood and practiced safe smoking techniques in designated areas may retain cigarettes/ lighter locked in a secured box in their room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 3 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure care plans included all components of care in regards to respiratory care and urinary tract infections. This affected two (Residents #15 and #16) of 19 residents whose care plans were reviewed. The facility census was 68. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Review of a five day minimum data set (MDS) assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff member for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the physicians orders revealed an order dated 09/24/19 for BiPap (a device that assists with breathing) at home setting at bedtime. Review of the care plan revealed it failed to include information related to use of BiPap at bedtime. This was verified during interview on 12/18/19 at 4:18 P.M. with Registered Nurse (RN) #144. 2. Resident #16 was admitted to the facility on [DATE] with the diagnoses including dementia and a history urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and mild depression. The resident required extensive assistance of one to two staff members for completion of Activities of Daily Living (ADLs). The resident received antibiotics on three of seven days prior to the assessment completion. A progress note, dated 11/10/19 revealed the resident displayed symptoms of a possible urinary tract infection and a dip stick returned positive results for a urinary tract infection. Resident #16 was started on antibiotics for treatment and the antibiotic was changed once the results from the culture for bacteria was received. Review of Resident #16's comprehensive care plan dated 09/25/19 showed the resident's history of urinary tract infections was not included in the care plan. Interview with the Director of Nursing (DON) #240 on 12/18/19 at 4:20 P.M. confirmed Resident #16 had a history of urinary tract infections which was not addressed in the resident's comprehensive care plan. DON #240 confirmed the resident should be monitored for signs and symptoms of a recurring urinary tract infection. Review of the facility policy, Plan of Care, revised on 08/16/17 stated the comprehensive plan of care will include information from all disciplines necessary or the care of resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 4 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to maintain accurate care plans related to alarms and the use of pain medications. This affected two (Resident #15 and Resident #1) of 19 residents reviewed for care plans. The facility census was 68. Findings include: 1. Resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Review of a five day minimum data set (MDS) assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff member for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the plan of care dated 11/19/19 revealed the resident was to have a mobility monitor on when in bed. Observations of Resident #15 from 12/16/19 to 12/18/19 revealed he had no mobility monitor in place while he was in bed. On 12/18/19 at 10:55 A.M. interview with Registered Nurse (RN) #144 revealed Resident #15 had no physician order for a mobility alarm. RN #144 verified the resident's care plan was inaccurate. #2. Review of Resident #1's medical record revealed the resident had a re-entry admission date on 05/17/19 with diagnoses including chronic obstructive pulmonary disease (COPD) Takotsubo syndrome (a sudden form of heart failure) chronic respiratory failure with hypoxia, cachexia (weakness of the body due to severe chronic illness) cardiac arrhythmia, syncope and collapse, restless leg syndrome, anxiety disorder, unspecified diastolic congestive heart failure, osteoarthritis, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident was admitted to hospice services on 05/27/19. Review of Resident #1's quarterly MDS dated [DATE] revealed the resident had intact cognition with mild depression symptoms. The resident required extensive assistance of one staff person to assist with Activities of Daily Living (ADLs). The resident received scheduled pain medications and non-medication interventions for pain. The resident reported occasional pain and daily opioid medications were administered to the resident. The resident received oxygen therapy and hospice care. Interview with Resident #1 on 12/17/19 at 1:35 P.M. revealed the resident had chronic pain in both shoulders. Interview with Licensed practical Nurse (LPN) #121 on 12/17/19 at 1:45 P.M. revealed Resident #1 received hospice care. The resident received Morphine on a routine basis, three times a day as well as Roxanol as needed for pain. LPN #121 stated the resident had not been taking the Roxanol until very recently. Resident #1 was using the as needed pain medication more frequently now. Interview with Resident #1 on 12/18/19 at 9:05 A.M. revealed the resident continued to complain of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 5 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0657 Level of Harm - Minimal harm or potential for actual harm pain in his shoulders. The resident voiced a pain level of eight out of ten for pain, which indicated a moderate pain level. Review of Resident #1's comprehensive care plan dated 05/21/19 revealed the care plan did not address pain monitoring or monitoring of narcotic pain medications. Residents Affected - Few Interview with the Director of Nursing (DON) #240 on 12/18/19 at 5:30 P.M. confirmed the resident received scheduled and as needed pain medications that should be monitored for side effects and included in the resident's plan of care. DON #240 confirmed Resident #1's comprehensive care plan did not address pain or monitoring narcotic pain medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 6 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 and staff interview the facility failed to ensure residents received necessary assistance with activities of daily living. This affected two (Resident #9 and #15) of two residents review for activities of daily living. The facility census was 68. Residents Affected - Few Findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease, respiratory failure and chronic obstructive pulmonary disease. Review of the annual minimum data set (MDS) dated [DATE] revealed his cognition was intact and he required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. Observation on 12/16/19 at 12:18 P.M. revealed his clothes were soiled with a brown substance and a dried white substance and he had unkempt facial hair. On 12/17/19 at 7:55 A.M. Resident #9 was wearing the same soiled clothing and was still unshaven. At 1:15 P.M. observation revealed the same stained clothes and he remained unshaven. On 12/17/19 at 1:17 P.M. interview with Registered Nurse (RN) #205 revealed the resident had asked if he had been dropped from hospice services that day because his aide had not been in. RN #205 reported they hadn't realized the hospice aide was on vacation and verified Resident #9's clothing was stained and he was in need of a shave. 2. Resident #15 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Review of a five day MDS dated [DATE] revealed his cognition was severely impaired and he required extensive assistance of one staff member for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Observation on 12/16/19 3:21 P.M. revealed Resident #15 was unshaven. On 12/17/19 at 8:00 A.M. and 2:00 P.M. the resident remained unshaven. On 12/18/19 at 8:51 A.M. and 10:45 A.M. Resident #15 was still unshaven and his fingernails were long, jagged and had a build up of a brown substance under some of them. This was verified at 10:45 A.M. by Licensed Practical Nurse (LPN) #245. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 7 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow physician orders in regards to obtaining daily weights. This affected one (Resident #67) of three residents reviewed for hospitalization. The facility census was 68. Residents Affected - Few Findings include: Resident #67 was admitted to the facility with diagnoses including congestive heart failure, diabetes and stage IV kidney disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. Review of physicians orders revealed an order dated 07/30/19 to obtain weights daily and to notify the physician if three pounds were gained in one day or five pounds gained in one week. Review of Resident #67's recorded weights revealed no evidence weights were obtained on 07/31/19, 08/01/19, 08/04/19, 08/07/19, 08/14/19, 8/16/19, 08/17/19, 08/18/19, 08/23/19, 08/30/19, 09/01/19, 09/05/19, 09/14/19, 09/15/19, 09/18/19, 09/19/19, 09/20/19, 09/28/19, 10/01/19, 10/04/19, 10/05/19, 10/09/19, 10/11/19, 10/12/19, 10/17/19, 10/19/19, 10/20/19, 10/23/19 to 10/30/19, 11/01/19, 11/02/19, 11/03/19, 11/06/19, 11/08/19 to 11/11/19, 11/14/19, 11/15/19, 11/21/19, 11/22/19, 11/23/19, 11/25/19, 11/28/19, 11/30/19, 12/01/19 and 12/08/19. On 12/19/19 at 10:43 A.M. interview with the Director of Nursing verified the lack of evidence weights were obtained daily as ordered for Resident #67. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 8 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview and policy review the facility failed ensure smoking materials were safely secured for one (Resident #25) of one resident reviewed for safe smoking. The affected one (Resident #25) and had the potential to affect two additional residents (#36 and #7). The facility census was 68. Findings include: 1. Clinical record review revealed Resident #25 was admitted on [DATE] with diagnoses including dementia, major depression, anxiety and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment which was considered severely impaired impaired cognition. Review of the smoking assessment dated [DATE] completed by Registered Nurse (RN) #127 revealed Resident #25 had cognitive loss, could light his own cigarettes, smoked two to five cigarettes daily, and the staff did not store his lighter and cigarettes. He was safe to smoke unsupervised, outside in the enclosed shelter. Review of the care plan (revised 11/14/19) revealed Resident #25 was independent and noncompliant with supervised smoking. He was allowed to keep his smoking materials including a lighter and cigarettes in his room and refused to give the supplies to the nurse to secure. 2. Clinical record review revealed Resident #7 was admitted on [DATE] with diagnoses including dementia, depression, anxiety and heart disease. Review of the MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident had a physician order dated 04/01/18 for as needed oxygen at three liters per minute via nasal cannula. Observations of Resident #7 revealed she lived in the room next to Resident #25. On 12/16/19 at 12:56 P.M. she was observed ambulatory/wandering around in the halls and in the vacant beauty shop across the hall from her room. The resident had an oxygen tank in her room at two liters. She was not observed attempting to enter Resident #25's room. 3. Clinical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including dementia, depression and anxiety. Review of the MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Multiple observations of Resident #36 from 12/16/19 to 12/19/19 revealed she wore a wanderguard and pushed herself around the facility in a wheelchair wandering inappropriately at times requiring staff redirection. She was frequently observed near but was not seen attempting to enter Resident #25's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 9 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/16/19 interviews were attempted with Residents #25, #7 and #36 but they were not able to give relevant or meaningful information. Interview with the Director of Nursing (DON) on 12/17/19 at 4:47 P.M. revealed it was a battle with Resident #25 who had friends/family that supplied his cigarettes and lighter which he kept in his room. This resident had been smoking since he was a young man. Interview on 12/17/19 at 5:30 P.M. with Licensed Practical Nurse (LPN) #204 revealed Resident #25 kept his cigarettes/lighter in his room but had never smoked in his room. He did not comply with the posted smoking schedule and became angry stating he was not in prison if anyone tried to secure his cigarettes/lighter or tell him to smoke at certain times. LPN #204 verified Resident #7 used oxygen in room next door to Resident #25 room and also wandered, but to her knowledge had never gone into Resident #25's room. Observation at that time with LPN #204 verified there were three packages of cigarettes and a lighter on the over bed table unsecured with no locked box in Resident #25's room. Resident #25 was laying on the bed and the table was next to him. Interview on 12/18/19 at 9:15 A.M. with LPN #111 verified both Residents #7 and #36 sometimes wandered into other residents' rooms. Interview with the Administrator on 12/18/19 at 10:15 A.M. revealed he realized Resident #25 had cigarettes/lighter unsecured in his room. The staff were trying to honor Resident #25's wishes to manage his own cigarettes/lighter. The Administrator verified Resident #25 was the only resident in the facility who smoked. Resident #25 had never smoked in his room or anywhere else inside the facility. There had been no incidents or accidents related to Resident #25 and smoking. The Administrator verified Resident #25 was cognitively impaired and should not be permitted to retain possession of smoking materials. Review of the smoking policy dated 06/12 revealed the purpose was to provide a safe environment for all residents and proper assistance for those residents who smoked. There were five designated smoking times for resident who required smoking supervision. A smoking assessment for each smoker determined if a resident may retain cigarettes and lighter in their room. An alert and oriented resident who understood and practiced safe smoking techniques in designated areas may retain cigarettes/ lighter locked in a secured box in their room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 10 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, staff interview and policy review the facility failed to provide physician ordered respiratory care for Resident #7. This affected one of two residents reviewed for respiratory care. The facility census was 68. Residents Affected - Few Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety and heart disease. Review of a physician's order dated 04/01/18 revealed the resident was to use oxygen (O2) at three liters per minute (LPM) as needed to keep her O2 saturation at 90 percent per checks by pulse oximeter (a device when attached to the finger determines O2 saturation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the Medication Administration Record (MAR) from 10/01/19 to present revealed no evidence the resident's O2 saturation levels were monitored. Review of documentation under the vitals tab revealed the resident's oxygen level was 90 percent on 10/07/19 and 11/06/19. A progress note dated 12/06/19 indicated the resident's O2 saturation was 85 percent with no evidence additional oxygen was administered per nasal cannula. A progress note dated 12/16/19 revealed the resident's O2 level was 80 percent with oxygen provided at three liters which effectively increased the resident's level to 93 percent. There was no other evidence found in the record that O2 saturation levels were checked. Observations of Resident #7 on 12/16/19 at 12:57 P.M., 12/17/19 at 2:10 P.M., and on 12/18/19 at 9:07 A.M. revealed the resident removed her oxygen nasal cannula and tubing. The oxygen tank in the resident's room was on and set to two LPM. Interview with Registered Nurse (RN) #144 on 12/18/19 at 1:35 P.M. verified Resident #7's as needed physician's order for oxygen at three LPM to keep the O2 saturation above 90 percent. RN #144 confirmed the order did not indicate how frequently nursing should monitor the pulse oximetry but it should be checked by the nurse and documented at least daily. RN #144 verified the lack of evidence Resident #7's O2 saturation level was consistently monitored. Review of the undated policy titled Oxygen Therapy revealed for residents receiving as need oxygen, the pulse ox was obtained prior to the initiation of oxygen for levels of 90 or below, then daily on the evening shift. The pulse ox was also checked monthly on the day shift after the resident was off the oxygen for at least 20 minutes to assess the need for the oxygen therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 11 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to stop administering blood pressure medication prior to dialysis at the dialysis center's request. This affected one (Resident #49) of one resident reviewed for dialysis treatment. The facility census was 68. Residents Affected - Few Findings include: Review of Resident #49's medical record revealed an admission date of 07/18/19 with the following medical diagnoses: aneurysm of artery of upper extremity, other complication of vascular dialysis catheter, aneurysm of artery of lower extremity, diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, chronic obstructive pulmonary disease (COPD), muscle weakness, essential primary hypertension (high blood pressure), dependency on renal dialysis (a process for purification of the blood) major depressive disorder, generalized anxiety disorder, and peripheral vascular disease. Review of Resident #49's physician orders showed an order for Metoprolol (antihypertensive) 12.5 milligrams (mg) to be given daily at 6:00 A.M. Review of Resident #49's Minimum Data Set (MDS) quarterly assessment dated [DATE] showed the resident had intact cognition and received dialysis treatments. Review of the Dialysis Communication form dated 10/23/19 revealed it indicated Please do not give any blood pressure medications prior to hemodialysis on Monday, Wednesday, Friday. Review of the Dialysis Communication form dated 11/13/19 stated, Please make sure to NOT give blood pressure meds pre-dialysis. Review of Resident #49's Medication Administration Record (MAR) dated October 2019 and November 2019 revealed the resident continued to receive Metoprolol at 6:00 A.M. from 10/24/19 through 11/12/19, then the administration time was changed to 9:00 P.M. Interview with Director of Nursing (DON) #240 on 12/19/19 at 11:20 A.M. confirmed the dialysis center had requested the facility staff not administer any blood pressure medications prior to the resident's dialysis treatments. DON #240 confirmed the resident continued to receive Metoprolol (a blood pressure medication) at 6:00 A.M. prior to the resident's dialysis treatments from 10/23/19, when the first request was made, until 11/13/19, when the request was communicated again. DON #240 confirmed the medication administration time should have been changed upon the first request from the dialysis center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 12 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 ensure the pharmacy identified perimeters for opioid medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 68. Findings include: Review of Resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Further review revealed a five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff members for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the physicians orders revealed orders on 09/24/19 for Tramadol HCL (opioid pain medication) 50 milligrams (mg) every six hours as needed for pain and Tramadol HCL 50 mg two tabs as needed every six hours for pain and on 11/15/19 Oxycodone Immediate (opioid pain medication) 5 mg one every four to six hours as needed for pain and Oxycodone Immediate 5 mg give two tablets every four to six hours. Review of the pharmacy notes on 11/21/2019 revealed Monthly Record Review completed. Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities (as defined in SOM [State Operations Manual] Appendix PP 483.60 (c)). Pharmacy failed to identify there were no perimeters set for the pain medication as when to administer one tablet or two tablets. On 12/18/19 at 10:15 A.M. interview with Director of Nursing verified there were no perimeters for the pain medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 13 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 and staff interview, the facility failed to ensure non-pharmacological interventions were attempted and blood pressures monitored prior to administration of medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 68. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, depression and anxiety. Further review revealed a five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff members for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the physicians orders revealed orders on 09/24/19 Tramadol HCL 50 milligrams (mg) every six hours as needed for pain and Tramadol HCL 50 mg two tablets as needed every six hours for pain and on 11/15/19 Oxycodone Immediate 5 mg one every four to six hours as needed for pain and Oxycodone Immediate 5 mg give two tablets every four to six hours. Review of the medication administration record (MAR) for 09/2019 revealed he received the Oxycodone on 09/24/19, 09/25/19, 09/26/19, 09/28/19, 09/29/19 and 09/30/19. Review of the MAR for 10/2019 revealed he received the Oxycodone on 10/01/19 , 10/02/19, 10/03/19, 10/05/19, 10/06/19, 10/07/19, 10/08/19, 10/10/19, 10/11/19, 10/12/19, 10/13/19, 10/14/19, 10/15/19, 10/16/19, 10/22/19, 10/23/19, 10/24/19, 10/25/19, 10/26/19 and 10/27/19. Review of the MAR for 11/2019 revealed he received the Oxycodone on 11/03/19, 11/05/19, 11/06/19, 11/07/19, 11/08/19, 11/09/19, 11/10/19, 11/12/19, 11/13/19, 11/14/19, 11/17/19, 11/19/19, 11/20/19, 11/21/19, 11/23/19, 11/24/19, 11/26/19/11/27/19, 11/29/19 and 11/30/19. Review of the MAR for 12/2019 revealed he received the Oxycodone on 12/01/19, 12/03/19, 12/05/19, 12/06/19, 12/07/19, 12/09/19, 12/10/19 and 12/11/19. Further review revealed the facility failed to attempt any non-pharmacological interventions prior to administering the pain medication. Review of the physician's orders revealed he received Lisinopril 20 mg daily, hold if the systolic blood pressure is less than 110 and the diastolic is less than 60. Review of the MAR for 10/2019 revealed the blood pressure was not documented on 10/02/19, 10/09/19, 10/10/19, 10/11/19, 10/13/19 to 10/31/19. Review of the MAR for 11/2019 and 12/2019 revealed no blood pressures were documented for the entire month. On 12/18/19 at 10:15 A.M. interview with Director of Nursing verified no non-pharmacological interventions were attempted prior to administration of the pain medication and the blood pressure was not monitored prior to administration of the Lisinopril. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 14 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #45's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, anxiety and delusional disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed her cognition was not intact. She required extensive assistance of one for bed mobility, dressing, eating, toileting and personal hygiene. Review of the Pharmacy Consultation report for 11/21/19 revealed Resident #45 is receiving Seroquel (antipsychotic) 50 mg at night time for behavioral or psychological symptoms of dementia. Please evaluate for a gradual dosage reduction attempt at this time. Response on 12/16/19 by the Certified Nurse Practioner (CNP) revealed the resident's dementia was worsening and her acting out behavior was increasing with all in contact with her. Review of Resident #45's documented behaviors revealed the only documented behaviors were one in 07/2019, 08/2019, two in 09/2019, none in 10/2019, 11/2019 and two for 12/2019. There was no documented evidence the behaviors had increased. There was no documented evidence for the justification of not attempting the gradual dose reduction. On 12/18/19 at 2:34 P.M. interview with the Director of Nursing verified the lack of documentation on behaviors and no increase in behaviors to justify not attempting the GDR with the Seroquel. Based on record review, observations, staff interviews and policy review, the facility failed to support the use of psychoactive medications for two (Residents #41 and #45) of five residents reviewed for unnecessary medications. The census was 68. Findings include: 1. Clinical record review revealed Resident # 41 was admitted on [DATE] with diagnosis including bipolar disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident had a physician's order dated 05/01/19 for a psychoactive medication (Risperidone), antipsychotic, at 1.0 milligram (mg) daily which was decreased to 0.5 mg on 12/17/19. Review of the resident's behavior intervention documentation in the Medication Administration Record (MAR) since 11/01/19 revealed there was nothing specific about what behaviors were monitored or evidence the resident was having any behaviors to support the use of the psychoactive medication. Review of the resident's progress notes since 11/01/19 revealed the only behavior noted was tongue chewing on 12/17/19. Multiple observations of the resident on 12/16/19 at 2:28 P.M., 12/17/19 at 9:21 A.M., 12/18/19 at 10:04 A.M. and 12/19/19 at 9:07 A.M. revealed the resident was in bed and appeared content. The surveyor observed no evidence of any behaviors. Interview on 12/19/19 at 9:25 A.M. with Registered Nurse (RN) #144 verified the behavior intervention documentation in the MAR since 11/01/19 had no evidence of behaviors noted or what specific (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 15 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 behaviors were monitored. RN #144 verified the only behaviors noted in the progress notes since 11/01/19 were on 12/17/19 regarding the tongue chewing resulting in the decrease of the Risperidone. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 16 of 17 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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 Based on observation, staff interview and policy and procedure review the facility failed to follow infection control guidelines in regards to cleaning a glucometer. This had the potential to affect four residents (Residents #21, #42, #67 and #273) who were ordered to have blood sugar checks by fingerstick on Station II. The facility census was 68. Residents Affected - Some Findings include: On 12/18/19 at 3:57 P.M. observation of a finger stick blood sugar (FSBS) for Resident #273 revealed Licensed Practical nurse (LPN) #245 obtained the FSBS using a glucometer. She then went to the medicine cart, placed a barrier on top of the cart and placed the glucometer on it. Using a sani cloth germicidal wipe, she wiped the glucometer for four seconds and left it on the barrier to dry, reporting it had to dry for five minutes. Review of the manufacturers guidelines on the container revealed it was to remain visibly wet for four minutes. On 12/19/19 at 8:53 A.M. LPN #245 verified she did not follow the facility policy or the manufacturer guidelines of cleaning the glucometer. Four residents (Residents #21, #42, #67 and #273) were identified on Station II as having FSBS orders and all used the same glucometer. Review of the facility policy Glucometer Usage and Cleaning (not dated) clean glucometer using germicidal wipe (with gloves on) wrap glucometer in the wipe place testing site down in a plastic cup. Needs to stay wet for four minutes. If wipe dries before four minutes, repeat process using two wipes. After four minutes you can take out and place in the individual space for the glucometer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 17 of 17