Inspection·December 21, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and facility policy and procedure review, the facility failed to honor residents shower preferences. This affected three residents (#22, #38, and #103) of six residents reviewed for activities of daily living. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 required extensive two staff assistance for transfers and bed mobility and extensive one staff assistance for toileting, personal hygiene, dressing, and bathing. Review of the care plan for Resident #103 dated 11/29/22 revealed the resident had an activities of daily living self care performance deficit related to amputation of second toe on right foot, osteomyelitis, cellulitis, vertigo, dementia and low back pain, he required assistance with bathing, hygiene and dressing and he prefers to have a shower twice weekly. Interventions included staff to set up equipment and assist as needed for bathing, dressing and hygiene and encourage independence. Review of the bathing documentation revealed Resident #103 received bed baths on 11/24/22, 11/25/22, 11/29/22, 12/01/22, 12/06/22, 12/07/22, and 12/13/22. On 12/12/22 the resident received his first shower at the facility. Interview on 12/12/22 at 1:11 P.M. with Resident #103 revealed he had only had one shower since he had been at the facility, and it was completed that day, 12/12/22. Interview on 12/14/22 at 11:55 A.M. with State Tested Nurse Assistant (STNA) #150 revealed they have only completed bed baths for Resident #103 because that was what was on the schedule, they never asked him if he wanted a shower, they just would tell him he was going to get washed up. She stated 12/12/22 was the first time she asked him if he wanted a shower and he said yes, so that was his first shower. Interview on 12/14/22 at 4:54 P.M. with the Director of Nursing (DON) confirmed Resident #103's care plan stated his preference was for showers but he was receiving bed baths instead. 2. Review of Resident #22's medical record revealed an admission date of 01/24/22. Diagnoses included schizoaffective disorder, obesity, muscle weakness, and benign prostatic hyperplasia with lower track symptoms. His admission data revealed he had a preference for showers two to three times a week in the evenings. Review of Resident #22 quarterly Minimum Data Set (MDS) 3.0, dated 10/01/22, revealed the resident had a moderate cognitive impairment, and required total dependence with one person physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 2 of 36 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 12/21/2022 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 0561 assistance for bathing. Level of Harm - Minimal harm or potential for actual harm Review of Resident #22's shower documentation from 11/14/22 to 12/08/22 revealed the resident was only receiving bed or towel baths, and had not received a shower in that time frame. Residents Affected - Few Review of Resident #22's care plan, dated 11/16/22, revealed the resident needed extensive assistance with bathing and his shower days are on Tuesday and Saturday in the evening. Interview on 12/13/22 at 1:31 P.M. with Resident #22 revealed he has not had a shower in over a month and would like them more frequently. He confirmed that he prefers showers over bed baths but they are not being done. Interview on 12/13/22 at 2:37 P.M. the Director of Nursing (DON) confirmed Resident #22's choices for showers were not being honored. Review of facility policy titled Bathing Frequency dated 03/12, revealed residents will be placed on a bathing schedule based on their preference. 3. Review of Resident #38's medical record revealed an admission date of 01/29/20. Diagnoses included seizure disorder, COPD, asthma, obesity, and difficulty in walking. His admission data revealed he had a preference for showers in the evening three times a week. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0, dated 9/16/22, revealed the resident was cognitively intact, and required one person physical assistance for bathing. Review of Resident #38's shower documentation from 11/14/22 to 12/08/22 revealed the resident was only receiving bed or towel baths, and had not received a shower in that time frame. Review of Resident #38's care plan, dated 10/0322, revealed the resident needed extensive assistance with bathing and his shower days are on Tuesday and Saturday in the evening evening. Interview on 12/12/22 at 12:26 P.M. Resident #38 revealed he hasn't had a shower in a awhile. Interview on 12/13/22 at 2:37 P.M. The DON confirmed Resident #38's choices for showers were not being honored. Review of facility policy titled Bathing Frequency dated 03/12, revealed the resident will be placed on a bathing schedule based on their preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 3 of 36 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 12/21/2022 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of the Self-Reported Incident (SRI), resident interview and staff interview the facility failed to ensure misappropriation of funds did not occur for Resident #13. This affected one resident (Resident #13) of two reviewed for misappropriation of property. Residents Affected - Few Findings included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis, diabetes, diabetic foot ulcer to the left foot, chronic kidney disease, atherosclerotic heart disease, gout, hyperlipidemia, hypothyroidism, obstructive sleep apnea, and benign prostatic hyperplasia. Review of the SRI report dated 08/31/22 revealed Resident #13 reported to a staff member he had money missing from his room. The staff member informed the Administrator who began an investigation. The Administrator spoke with Resident #13 who stated it was $200.00 in a bank envelope and it was last seen the week prior. Resident #13 indicated his wallet had went through the washer and dryer so he had set the money out to dry around his room. A nurse aide came in and noticed the money lying around, put it back into the envelope and handed it to his nurse aide. The second nurse aide decided to put the envelope in a drawer in the resident's room instead of locking it up in the nurse's cart since it was after 7:00 P.M. and there was no office staff to secure it in the front office. The Administrator contacted the local police department and had an officer come out to speak with Resident #13. The officer came out and spoke with him. There were no witnesses to the money going missing and alleged misappropriation. The allegation of misappropriation was substantiated. Review of the quarterly Minimum Data Set 3.0 dated 10/14/22 revealed Resident #13 had intact cognition. Review of the progress notes from 08/20/22 to 09/10/22 revealed no documentation of the incident. On 12/14/22 at 12:05 P.M. interview with Resident #13 revealed he went to the bank and got $200.00. He stated he owed his niece $40.00 and he gave that to her which left him with $160.00. He stated a couple days later his wallet had gone through the wash and a staff member brought it back to him with all the money in it. However, he did not know who it was. He stated he laid the money out on the window sill to dry with his wallet, once it was dried he gathered it up and stacked it in a pile on his stand. He stated a staff member came in and told him he should not have his money laying out. She took it and placed it in his clothes closet. He stated about a week later he went to get his wallet because he was going out and all of his money was gone. He stated he reported it immediately to the staff. He indicated it was never replaced. On 12/14/22 at 12:30 P.M. interview with the Administrator revealed he had investigated the missing money of Resident #13 and due to staff seeing him have the money then it was missing; he substantiated the allegation of misappropriation, however he verified he did not have any documentation to support he had interviewed any of the staff or other residents concerning the incident or misappropriation of property. Review of the undated facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revealed it was the facility's policy to investigate all alleged violations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 4 of 36 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 12/21/2022 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 0602 Level of Harm - Minimal harm or potential for actual harm involving abuse, neglect,exploitation, mistreatment of a resident, or misappropriation of resident property, including Injuries from an unknown source. Additionally, the facility should immediately report all such allegations to the Administrator and/or designee. In cases where a crime is suspected, staff should also report the same to local law enforcement. The Administrator or designee will report the allegations to the Ohio Department of Health. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00131751. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 5 of 36 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 12/21/2022 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's investigation, staff interview, and facility policy review, the facility failed to report an allegation of verbal abuse for one resident (Resident #102). This affected one (Resident #102) of two residents reviewed for abuse/misappropriation. The facility census was 51. Findings Include: Review of the closed medical record for former Resident #102 revealed an admission date on 04/05/22 and a discharge date on 04/08/22. Medical diagnoses included paroxysmal atrial fibrillation, type II diabetes mellitus, and weakness. Review of the admission assessment dated [DATE] revealed Resident #102 was alert to person, place, and time and was verbally appropriate. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 required limited assistance from one staff to complete Activities of Daily Living. The resident's cognition was not assessed at the time of the MDS assessment. Review of progress notes dated from 04/01/22 to date of discharge on [DATE] revealed there were not any notes related to an allegation of verbal abuse. On 04/08/22 at 4:04 A.M., Resident #102 decided to leave at 3:00 A.M. Against Medical Advice (AMA) due to what she believed to be inadequate care. The resident's family and the resident had a normal mental status and adequate capacity to make medical decisions. At 4:00 A.M., Resident #102 left the facility with the family in the family's vehicle. On 04/08/22 at 9:07 A.M., a note stated that staff reported that Resident #102 left AMA at 4:00 A.M. with family. Hand written admission paperwork was signed on 04/07/22, but was unable to get computer to connect to electronic admission paperwork after several attempts. Resident discharged prior to signing AMA paperwork. Review of the care plan dated 04/05/22 revealed Resident #102 was admitted for nursing and rehab services and her goal was to be able to return home when she felt more independent. Resident #102 was alert and oriented with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident's mood score was four out of 27. Resident #102 preferred to concentrate on therapy with the goal to return home with her spouse. Review of the facility investigation dated 04/08/22 revealed the Director of Nursing (DON) received a call from Registered Nurse (RN) #110 at 3:00 A.M. reporting Resident #102 was very upset with Temporary Nurse Aide (TNA) #180 and had called her a bitch. RN #110 stated Resident #102 called her husband and family to come and pick her up. The DON instructed RN #110 to listen to the family and Resident #102 and if the resident insisted on leaving to request a signature on AMA paperwork. The DON had also requested RN #110 and TNA #180 document statements of what had occurred to upset Resident #102. On 04/08/22 at 10:00 A.M., the DON contacted Resident #102 at her home via telephone. Resident #102 explained she had turned on her call light at 2:35 A.M. and waited for ten to 15 minutes for assistance up to the bedside commode. Resident #102 got up without assistance at that time due to no staff response and set off the mobility alarm. TNA #180 responded to the alarm and entered the room with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 6 of 36 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 12/21/2022 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an attitude and was disrespectful to Resident #102. TNA #180 turned off the alarm and the call light and Resident #102 thought TNA #180 said, the F word. TNA #180 left Resident #102 on the bedside commode and did not offer to assist her back to bed. RN #110 returned to the resident's room later with TNA #180 to discuss what had occurred and TNA #180 continued to be disrespectful toward her and believed the aide called her a bitch and used the F word. Resident #102 also stated TNA #180 had raised her voice and called the resident a liar. Review of the written statement from RN #110 dated 04/08/22 revealed TNA #180 had responded to a bed alarm in Resident #102's room. When RN #110 returned from lunch break, TNA #180 had just left the resident's room and informed Resident #102 wanted to see the nurse. RN #110 went to the resident's room where she was found in bed. Resident #102 informed RN #110 she had called her family to pick her up and take her home because TNA #180 came in my room with all kinds of attitude, dropped the F-bomb on me, then called me a bitch. RN #110 requested Resident #102 explain again exactly what happened and Resident #102 again stated TNA #180 dropped the F-bomb and called me a bitch. After receiving a full statement from Resident #102, RN #110 left the room to get AMA paperwork and called the DON to notify Administration of the situation. Review of the written statement from TNA #180 revealed Resident #102's bed alarm sounding and responded to the resident's room and found Resident #102 up without assistance. TNA #180 asked the resident if she was supposed to be up by herself and Resident #102 responded she had been waiting for assistance for 20-30 minutes. TNA #180 denied the resident had waited that long for assistance. TNA #180 apologized to Resident #102 for having to wait and explained she was assisting another resident. Resident #102 became upset and replied that she was a patient too and deserved just as much attention as the next person and proceeded to call TNA #180 a bitch. Interview on 12/15/22 at 9:38 A.M. with the DON confirmed she had completed an investigation but did not report the allegation of verbal abuse or opened a Facility-Reported Incident (FRI) related to the allegation. The DON confirmed RN #110 called her to report the incident and confirmed she would consider the allegation made by Resident #102 to be an allegation of verbal abuse. Review of the facility policy, Levering Management Inc. Policy and Procedure on Abuse, Neglect, Exploitation & Misappropriation of Resident Property, undated, revealed the policy stated, all incident and allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property and all injuries of unknown origin must be reported immediately to the Administrator or designee. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Administrator and/or designee of the facility will report to Ohio Department of Health (ODH) in accordance with state law. This deficiency represents non-compliance investigated under Complaint Number OH00131751. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 7 of 36 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 12/21/2022 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 0610 Respond appropriately to all alleged violations. 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, review of facility Self-Reported Incident (SRI), policy review, resident interview and staff interviews the facility failed to thoroughly investigate allegation of misappropriation for Resident #13 and verbal abuse for Resident #102. This affected two residents (Resident #13 and #102) of 17 reviewed for abuse. Residents Affected - Few Findings included: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis, diabetes, diabetic foot ulcer to the left foot, chronic kidney disease, atherosclerotic heart disease, gout, hyperlipidemia, hypothyroidism, obstructive sleep apnea, and benign prostatic hyperplasia. Review of the SRI report dated 08/31/22 revealed Resident #13 reported to a staff member he had money missing from his room. The staff member informed the Administrator who began an investigation. The Administrator spoke with Resident #13 who stated it was $200.00 in a bank envelope and it was last seen the week prior. Resident #13 indicated his wallet had went through the washer and dryer so he had set the money out to dry around his room. A nurse aide came in and noticed the money lying around, put it back into the envelope and handed it to his nurse aide. The second nurse aide decided to put the envelope in a drawer in the resident's room instead of locking it up in the nurse's cart since it was after 7:00 P.M. and there was no office staff to secure it in the front office. The Administrator contacted the local police department and had an officer come out to speak with Resident #13. The officer came out and spoke with him. There were no witnesses to the money going missing and alleged misappropriation. The allegation of misappropriation was substantiated. Review of the quarterly Minimum Data Set 3.0 dated 10/14/22 revealed Resident #13 had intact cognition. Review of the progress notes from 08/20/22 to 09/10/22 revealed no documentation of the incident. On 12/14/22 at 12:05 P.M. interview with Resident #13 revealed he went to the bank and got $200.00. He stated he owed his niece $40.00 and he gave that to her which left him with $160.00. He stated a couple days later his wallet had gone through the wash and a staff member brought it back to him with all the money in it. However, he did not know who it was. He stated he laid the money out on the window sill to dry with his wallet, once it was dried he gathered it up and stacked it in a pile on his stand. He stated a staff member came in and told him he should not have his money laying out. She took it and placed it in his clothes closet. He stated about a week later he went to get his wallet because he was going out and all of his money was gone. He stated he reported it immediately to the staff. He indicated it was never replaced. On 12/14/22 at 12:30 P.M. interview with the Administrator verified he only had three hand written pages of notes from his investigation. He verified he had not interview all staff members who had been in the room of Resident #13 when his money had gone missing, he had not interviewed all the staff who had been working the time the money had gone missing, and he had not interviewed any other residents to verify they had not had any issues with missing money. Review of the undated facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 8 of 36 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 12/21/2022 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident Property, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect,exploitation, mistreatment of a resident, or misappropriation of resident property, including Injuries from an unknown source. Additionally, the facility should immediately report all such allegations to the Administrator and/or designee. In cases where a crime is suspected, staff should also report the same to local law enforcement. The Administrator or designee will report the allegations to the Ohio Department of Health. Investigations regarding misappropriation consisted of interviews with the person or persons reporting the incident, witness to the incident and with staff who had contact with the resident during the relevant periods or shifts of the alleged incident 2. Review of the closed medical record for former Resident #102 revealed an admission date on 04/05/22 and a discharge date on 04/08/22. Medical diagnoses included paroxysmal atrial fibrillation, type II diabetes mellitus, and weakness. Review of the admission assessment dated [DATE] revealed Resident #102 was alert to person, place, and time and was verbally appropriate. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 required limited assistance from one staff to complete Activities of Daily Living. The resident's cognition was not assessed at the time of the MDS assessment. Review of progress notes dated from 04/01/22 to date of discharge on [DATE] revealed there were not any notes related to an allegation of verbal abuse. On 04/08/22 at 4:04 A.M., Resident #102 decided to leave at 3:00 A.M. Against Medical Advice (AMA) due to what she believed to be inadequate care. The resident's family and the resident had a normal mental status and adequate capacity to make medical decisions. At 4:00 A.M., Resident #102 left the facility with the family in the family's vehicle. On 04/08/22 at 9:07 A.M., a note stated that staff reported that Resident #102 left AMA at 4:00 A.M. with family. Hand written admission paperwork was signed on 04/07/22, but was unable to get computer to connect to electronic admission paperwork after several attempts. Resident discharged prior to signing AMA paperwork. Review of the care plan dated 04/05/22 revealed Resident #102 was admitted for nursing and rehab services and her goal was to be able to return home when she felt more independent. Resident #102 was alert and oriented with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident's mood score was four out of 27. Resident #102 preferred to concentrate on therapy with the goal to return home with her spouse. Review of the facility investigation dated 04/08/22 revealed the Director of Nursing (DON) received a call from RN #110 at 3:00 A.M. reporting Resident #102 was very upset with Temporary Nurse Aide (TNA) #180 and had called her a bitch. RN #110 stated Resident #102 called her husband and family to come and pick her up. The DON instructed RN #110 to listen to the family and Resident #102 and if the resident insisted on leaving to request a signature on AMA paperwork. Also requested RN #110 and TNA #180 document statements of what had occurred to upset Resident #102. On 04/08/22 at 10:00 A.M., the DON contacted Resident #102 at her home via telephone. Resident #102 explained she had turned on her call light at 2:35 A.M. and waited for ten to 15 minutes for assistance up to the bedside commode. Resident #102 got up without assistance at that time due to no staff response and set off the mobility alarm. TNA #180 responded to the alarm and entered the room with an attitude and was disrespectful to Resident #102. TNA #180 turned off the alarm and the call light (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 9 of 36 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 12/21/2022 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 0610 Level of Harm - Minimal harm or potential for actual harm and Resident #102 thought TNA #180 said, the F word. TNA #180 left Resident #102 on the bedside commode and did not offer to assist her back to bed. RN #110 returned to the resident's room later with TNA #180 to discuss what had occurred and TNA #180 continued to be disrespectful toward her and believed the aide called her a bitch and used the F word. Resident #102 also stated TNA #180 had raised her voice and called the resident a liar. Residents Affected - Few Review of the written statement from RN #110 dated 04/08/22 revealed TNA #180 had responded to a bed alarm in Resident #102's room. When RN #110 returned from lunch break, TNA #180 had just left the resident's room and informed Resident #102 wanted to see the nurse. RN #110 went to the resident's room where she was found in bed. Resident #102 informed RN #110 she had called her family to pick her up and take her home because TNA #180 came in my room with all kinds of attitude, dropped the F-bomb on me, then called me a bitch. RN #110 requested Resident #102 explain again exactly what happened and Resident #102 again stated TNA #180 dropped the F-bomb and called me a bitch. After receiving a full statement from Resident #102, RN #110 left the room to get AMA paperwork and called the DON to notify Administration of the situation. Review of the written statement from TNA #180 revealed Resident #102's bed alarm sounding and responded to the resident's room and found Resident #102 up without assistance. TNA #180 asked the resident if she was supposed to be up by herself and Resident #102 responded she had been waiting for assistance for 20-30 minutes. TNA #180 denied the resident had waited that long for assistance. TNA #180 apologized to Resident #102 for having to wait and explained she was assisting another resident. Resident #102 became upset and replied that she was a patient too and deserved just as much attention as the next person and proceeded to call TNA #180 a bitch. Interview on 12/15/22 at 9:38 A.M. with the DON confirmed TNA #180 completed her shift on 04/08/22 after RN #110 had called to notify of her of the allegation of verbal abuse made by Resident #102. The DON also confirmed she had not interviewed any additional residents or staff about the allegation other than RN #110. Review of the facility policy, Levering Management Inc. Policy and Procedure on Abuse, Neglect, Exploitation & Misappropriation of Resident Property, undated, revealed the policy stated, If a staff member is accused or suspected of abuse, neglect exploitation, mistreatment of a resident, or misappropriation of resident property, the facility should remove the staff member from the facility and the schedule pending the outcome of the investigation. When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of the appropriate personnel. The investigation will include: resident's statements, resident's roommate statement (if applicable), involved staff and witness statements of events, a description of the resident's behavior and environment at the time of the incident, injuries present including a resident assessment, observation of resident and staff behaviors during the investigation, environmental considerations, all staff must cooperate during the investigation to assure the resident is fully protected. This deficiency represents non-compliance investigated under Complaint Number OH00131751. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 10 of 36 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 12/21/2022 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of Pre-admission Screening and Resident Reviews (PASARRs), and facility policy review, the facility failed to update PASARR screenings when two residents (Resident #31 and #34) had additional mental health diagnoses added. This affected two (Residents #31 and #34) of two residents reviewed for PASARR screenings. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date on 02/25/19. Medical diagnoses included unspecified dementia with agitation (10/01/22), Major Depressive Disorder-recurrent (02/25/19), delusional disorders (08/21/19), anxiety disorder (03/29/20), hallucinations (08/21/19), and cognitive communication deficit (02/25/19). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and scored ten out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident scored two out of 27 on the PHQ-9 assessment for depression. No behaviors were indicated. Resident #34 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the Pre-admission Screening and Resident Review (PASARR) dated 02/28/19 revealed there was no indication Resident #34 had a diagnosis of dementia. The only mental health diagnosis included on the PASARR was major depressive disorder. Interview on 12/13/22 at 11:07 A.M. with the Business Office Manager (BOM) #100 confirmed there were no other mental health diagnoses or dementia included on the PASARR. Review of the facility policy, PASARRS, undated, revealed the policy stated, if a resident experiences a significant change in health (improvement or decline) a new PASARR must be completed. 2. Review of Resident #31's record revealed an admission date of 03/15/22. Diagnoses dated 03/15/22 included bipolar disorder, major depressive disorder, and anxiety disorder. Additionally a new diagnosis of hallucinations was added on 03/20/22. Review of Resident #31's pre-admission screening and resident review (PASARR), dated 03/14/22, indicated the resident did not have a mental health diagnosis. Interview on 12/13/22 at 11:07 A.M. Business Office Manager #100 confirmed that Resident #31's PASARR did not indicate her mental illnesses. She stated the screening was done at hospital and the facility did not get an updated one completed upon her admission to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 11 of 36 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 12/21/2022 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** 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depressive disorder, neuromuscular dysfunction of the bladder, obstructive sleep apnea, anxiety disorder, anemia, asthma, cramps and spasms. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition. Review of the care conference sheet dated 08/09/22 revealed the care conference was done via phone with the daughter without the resident present. Review of the progress note dated 11/02/22 at 2:40 P.M. revealed a care conference was done with Resident #5 and she voiced no concerns. There was not a care conference sheet dated 11/02/22. On 12/12/22 at 1:46 P.M. an interview with Resident #5 revealed she did not think she had ever been invited to a care conference meeting to discuss her care. On 12/13/22 at 2:29 P.M. interview with Registered Nurse (RN) #115 verified the facility has been doing care conferences over the phone with the residents families or responsible party since the pandemic hit. RN #115 verified no other staff or the resident were in attendance for these telephone conferences. She stated they would speak to the residents separately but not with the interdisciplinary team (IDT). She verified there was no care conference sheet verifying Resident #5 had attended the meeting. On 12/13/22 at 4:20 P.M. interview with the Director of Nursing revealed the facility mostly did IDT meetings with the skilled residents and families and for the long-term care resident they have been doing the care conference over the phone with the families. She stated it was more convenient for the families that way. Based on interview and record review the facility failed to provide quarterly care conferences for Resident#17 and failed to invite Resident #5 to her care conference. This affected two (#5 and #17) of two residents reviewed for care conferences. The facility census was 51. Findings include: 1. Review of Resident #17's medical record revealed an admission date 03/25/20. Diagnoses included paraplegia, multiple sclerosis, and trigeminal neuralgia. Review of Resident #17's Minimum Data Set 3.0, dated 10/14/22, revealed the resident had intact cogitation. Interview on 12/12/22 at 10:02 A.M. Resident #17 revealed he did not recall ever being invited to a care conference meeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 12 of 36 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 12/21/2022 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a yearly look back of care conferences from 12/2021 through 12/2022 revealed the resident had only had one care conference on 08/30/22. Interview on 12/14/22 at 12:54 P.M. with Licensed Practical Nurse (LPN) #105 who is in charge of setting up care conferences revealed the resident has only had one care conference this year which was on 8/30/22. LPN #105 stated she is unsure as to why so many have been missed. Event ID: Facility ID: 365269 If continuation sheet Page 13 of 36 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 12/21/2022 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 Based on observation, interview, and record review the facility failed to assist Resident #38 and Resident #154 with nail care. This affected two (#38, #154) of two residents reviewed for nail care. The facility census was 51. Residents Affected - Few Findings include: Review of Resident #38's medical record revealed an admission date of 01/29/20. Diagnoses included seizure disorder, COPD, asthma, obesity, and difficulty in walking. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0, dated 9/16/22, revealed the resident was cognitively intact, and required one person physical assistance for bathing and set up help for personal hygiene. Observation on 12/12/22 at 12:26 P.M. revealed Resident #38 was noted to have long, dirty, jagged finger nails. Interview at this time with Resident #38 revealed no one has cut them (finger nails) in awhile, but he would like them cut. Interview on 12/13/22 at 9:57 A.M. with the Director of Nursing (DON) verified the resident had long, dirty, jagged nails that needed cut. 2. Review of Resident #154's medical record revealed an admission date of 12/06/22. Diagnoses included mild intellectual disabilities, hypertension, and metabolic encephalopathy. Observation on 12/12/22 at 10:44 A.M. revealed Resident #154 was noted to have long, dirty, jagged finger nails. Interview at this time with Resident #154 revealed he hasn't had his nails trimmed since he has been at the facility and would like them cut. Interview on 12/13/22 at 9:52 A.M. with the DON confirmed the resident's nails were long, jagged, dirty, and needed cut. Review of Resident #154 MDS 3.0 dated 12/12/22 revealed the resident had a moderate cognitive impairment, and needed one person physical assist for personal hygiene. Review of the undated facility titled STNA Nursing Assistant Duties paper revealed fingernail cleaning and trimming should be done as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 14 of 36 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 12/21/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy and procedure, the facility failed to ensure pressure ulcer interventions were in place. This affected one resident (#37) out of one resident reviewed for pressure. The facility identified one resident (#37) with pressure ulcers. The census was 51. Residents Affected - Few Findings Include: Review of the medical record for Resident #37 revealed an admission date of 04/10/19 and the diagnoses of paraplegia, colostomy, protein calorie malnutrition, diabetes type two, spinal stenosis, and reflex neuropathic bladder. Review of the Braden pressure ulcer risk assessment dated [DATE], revealed Resident #37 was at low risk for developing a pressure ulcer. Review of the care plan dated 04/22/19 and updated 11/23/22 revealed Resident #37 had a history of wounds with multiple dates and stages of differing wounds. Interventions included encourage 80 to 100% of diet, float heels off bed, low air loss mattress to bed, encourage turning and repositioning at two hour intervals, he has refused at times, staff to provide education on the benefits of turning and risks of not turning, and see physician orders for current treatments. Review of the wound assessments for Resident #37 revealed on 11/09/22 the resident had a Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer to his right buttocks measuring 3 centimeters (cm) by 1.5 cm by 0.1 cm, there was a small amount of serosanguinous exudate and no odor and this was a wound that had reopened. The physician ordered Alginate and foam daily and as needed. Weekly assessments were completed and the wound was improving until 12/13/22 the wound measured 3.8 cm by 3.5 cm by 0.1 cm, there was a moderate amount of blood, no odor, but the wound was worsening with orders to apply collagen and sacral foam daily and as needed. The interventions plan for the wound was to reposition as tolerated and an alternating pressure mattress on 200 pounds. The physician assumed the resident might have a wound infection due to the increased friability of the wound. Observation on 12/14/22 at 2:56 P.M. with Licensed Practical Nurse (LPN) #109 revealed Resident #37's low air loss bed was set for 240 pounds and confirmed that it should be 200 pounds per the wound note plan. LPN #109 stated sometimes the bed gets bumped and the pounds get changed. Review of the facility policy and procedure titled Skin Care Policy, undated, revealed it was the policy of the facility to prevent and/or treat skin breakdown through a process of identification, daily monitoring, treatment, and re-evaluation that is based on the residents individual assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 15 of 36 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 12/21/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to ensure Resident #35's splinting program was initiated per therapy recommendations. This affected one (#35) of two residents reviewed for therapy recommendations. The facility census was 51. Findings include: Review of Resident #35's medical record revealed an admission date of 09/24/19. Diagnoses included Alzheimer's Disease, chronic pain syndrome, and osteoarthritis. Various observations from 12/12/22 through 12/14/22 revealed Resident #35 had a paper indicating a splinting program protocol sheet on her wall but the resident was not wearing any splints during this time. Her bilateral hands were noted to be contracted during the observations. Review of Resident #35's quarterly Mimium Data Set 3.0, dated 09/07/22, revealed she had impaired cognition and needed total dependence of one person with physical assist for personal hygiene. Review of Resident #35's Occupational Therapy Discharge Summery, dated 05/20/22, revealed the resident and staff will demonstrate 100 percent carry over of contracture management strategies for the resident's right hand to maintain skin integrity and decrease further contractions. Instructions were to wear the right hand splint for approximately four hours as tolerated during the day, and wear the left hand splint eight hours as tolerated during the night. Interview on 12/13/22 at 12:41 P.M. Therapy Manager #160 revealed Resident #35 was seen from 04/11/22 through 05/20/22 for Occupational and Physical Therapy. A recommendation was made upon discharge for hand splints. She stated she put the splints in the resident's room and informed staff about the splints. Interview on 12/13/22 at 12:39 P.M. with Licensed Practical Nurse (LPN) #109 revealed she did not know that Resident #35 had a splinting program. Review of Resident #35's medical record revealed there was not any staff documentation regarding a splint program for the resident and the resident did not have a care plan regarding contracture's or splints. Interview on 12/14/22 at 10:39 A.M. with the facility's Director of Nursing (DON) revealed the therapy director did not make her aware of the recommendation for Resident #35's splinting program. The DON stated that since she was not notified of the splinting program she will have to contact the physician for splint orders, add to the care plan, and train staff so the splinting program can be implemented. The DON confirmed an order was not obtained, the care plan was not initiated, and staff were not trained on the program for Resident #35. The DON also stated the facility does not have a policy addressing implementation of therapy recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 16 of 36 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 12/21/2022 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 observation, medical record review, staff interview, resident interview, family interview, and facility policy and procedure review, the facility failed to ensure residents were not left unattended while unresponsive, resulting in a fall for Resident #103, and failed to thoroughly investigate a fall for Resident #38. This affected two residents (#38 and #103) out of four Residents reviewed for accidents. The census was 51. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 required extensive two staff assistance for transfers and bed mobility and extensive one staff assistance for toileting, personal hygiene, dressing, and bathing. Review of the care plan for Resident #103 dated 11/29/22 revealed the resident had an activities of daily living self care performance deficit related to amputation of second toe on right foot, osteomyelitis, cellulitis, vertigo, dementia and low back pain, he required assistance with bathing, hygiene and dressing and he prefers to have a shower twice weekly. Interventions included staff to set up equipment and assist as needed for bathing, dressing and hygiene and encourage independence. The care plan also stated the resident had an alteration in self mobility, he was at risk for injury from falls related to amputation of second toe on right foot, dementia and impaired balance with interventions to be sure call light is within reach and encourage its assistance, keep in good body alignment, assist with mobility, transfers and ambulation, and anticipate the residents needs. Review of the fall risk assessments dated 11/23/22 and 12/12/22 revealed Resident #103 was high risk for falls. Review of the fall investigation dated 12/12/22, revealed Resident #103 was receiving a shower when he became lethargic and non-responsive, he fell out of the shower chair, abrasions were noted to his forehead and left knee, he was placed back in bed. Related factors were incontinence, confusion/disorientation, being hearing impaired, and acute conditions. The witness statements revealed State Tested Nurse Assistant (STNA) #150 was giving Resident #103 a shower in the station three shower room, she was washing and rinsing the resident off when he went lethargic and would not respond to her. STNA #150 went to the shower room door to yell for assistance and he fell out of the shower chair. Help arrived and they returned the resident to bed, he sustained an abrasion to forehead and left knee, the physician and family were notified. The new intervention was for two staff assistance while in the shower. Review of the Director of Nursing (DON) witness statement revealed she heard STNA #150 yell for assistance in the shower room, when she arrived, the resident was on the floor in front of the shower chair. Respirations were unlabored and the resident was talking, he was rolled to his back with four staff assistance and an assessment was performed, an abrasion was noted to the forehead and left knee. He was assisted back to the shower chair. Neurological checks were initiated and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 17 of 36 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 12/21/2022 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 resident complained of slight discomfort in left knee but denied headache, his knee was cleansed and dressings were applied. Review of the nurses note dated 12/12/2022 at 10:28 A.M. revealed Resident #103 was receiving a shower, when he became unresponsive and fell out of the shower chair. An abrasion was noted to his forehead and left knee, and the resident denied any pain or discomfort. The resident's responsible parties and physician were notified of the incident, he will be continuously monitored and there were no further concerns at that time. Interview on 12/12/22 at 12:47 P.M. with Resident #103 revealed he was in the shower that morning and two staff dropped him in shower. He stated he received an abrasion to the top of his head and he bumped his knee. Interview on 12/14/22 at 11:47 A.M. with Licensed Practical Nurse (LPN) #109 revealed the aide (STNA #150) had Resident #103 in shower and he went unconscious/unresponsive, and went face forward out of shower chair. He received an abrasion on the top of his head and left knee. The physician just said to continue neurological checks and he wasn't too worried. LPN #109 stated STNA #150 should not have left Resident #103 while he was unconscious, but she was too far from a cord and you can't hear anything in the shower room if someone were to yell for help. Interview on 12/14/22 at 11:55 A.M. with STNA #150 revealed she took Resident #103 to the shower in station #3 shower room and he was in a shower chair. As she was washing him up, he went lethargic and he wouldn't respond. She went to the shower door and hollered for help and in the timeframe she left him to go to the door, he fell on the floor. She stated staff showed up to help and assessed him, got him off the floor and got him to his room. She stated he had never gone lethargic like that before and they were talking to him during the incident and he didn't even know or remember that he had fallen. Observation on 12/14/22 at 12:03 P.M. with STNA #150 revealed the station #3 shower room. She pointed that the resident was being showered in the far shower, away from the door, approximately five paces away from the door to the hallway, and a call light was noted on the shower wall. When asked if she could have used the call light in the shower to notify someone of the need for assistance, she stated she didn't even remember there was a call light in the shower room. When asked to see if the call light worked, STNA #150 pulled the call light cord and it was observed that the call light outside of the shower room was not lit up and the call light at the call light board at the nurses station was not lit up. STNA #150 confirmed the call light in the shower did not work. She stated she is glad she didn't try the call light knowing that now. STNA #150 also stated in the past they had used walkie talkies and that would have been helpful had they continued to use them, which they hadn ' t. Interview on 12/14/22 at 12:05 P.M. with STNA #150 and LPN #109 revealed a conversation between the two staff, neither were aware the call light in the shower didn't work and LPN #109 stated she would put in a trouble ticket for that call light. Interview on 12/14/22 at 4:48 P.M. with the Director of Nursing (DON) revealed STNA #150 panicked a little when she thought the resident was becoming unresponsive, she knew she needed help quickly and she stepped away. She revealed Resident #103 was in the shower chair without the belt on and leaning on the shower bed nearby, so she thought he was stable when she left him. The DON stated there is a belt on the shower chair and they told her she should have put the belt on him, but they are so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 18 of 36 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 12/21/2022 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 concerned about restraints, and she asked herself, when he went forward would the chair have gone too. The new intervention for this was that he was to be a two staff assistance for shower. The DON revealed when she was in the shower with him after the fall, he was talking and a little dazed, but he was fine and didn't seem unconscious. He also did ask how he skinned his knee, he didn't realize he fell. She revealed the resident's neurological checks and vital signs were within normal limits post fall and STNA #150 received education regarding never to walk away from someone in that situation. Review of the facility policy and procedure titled, Use of Call Light, undated, revealed the purpose was to respond promptly to the residents call for assistance and to assure a call system was in place and in proper working order. It also stated the emergency call lights should be in functioning order. The policy specifically stated the emergency call lights in bathrooms and shower/tub rooms would have a light and a continuous sound that will appear over the door of the room and on the board at the nurses station. 2. Review of Resident #38's medical record revealed an admission date of 01/29/20. Diagnoses included seizure disorder, COPD, difficulty in walking, and osteoarthritis. Review of Resident #38's quarterly Minimum Data Set 3.0, dated 09/16/22, revealed the resident was cognitively intact and independent with a walker for in and out of room ambulation. Review of Resident #38's nursing notes, dated 12/6/22 at 1:05 P.M., revealed a State Tested Nursing Aide (STNA) notified the nurse the resident was noted to be on the bedroom floor. The nurse observed the resident laying on his left side. She obtained vital signs, a blood pressure of 140/70, pulse of 80, and oxygen saturation of 95 percent. The resident had complaints of left hip discomfort and was sent to the hospital to be evaluated related to repeat falls, change of condition, and hip pain. The Nursing note did not indicate if the resident's fall interventions were in place, if the resident hit his head, what the resident was doing prior to his fall. Continued review of the resident's medical record revealed there was not an investigation into the fall. Review of Resident #38's hospital information, dated 12/06/22, revealed the resident was seen on this date due to repeated falls. He received an CT of head and X-ray of his right knee with negative findings. He was tested and discharged with a diagnosis of influenza A. Interview on 12/14/22 at 2:58 P.M. with the DON revealed she was never made aware of the Resident #38's 12/06/22 fall. She stated that an agency nurse was working, and it did not get reported. She stated she did not have an investigation, witness statements, proper assessment, and new interventions were not put into place. Review of the facility policy, Fall Prevention and Management Policy and Procedure dated 02/2018, revealed when a fall occurs the nurse will complete an incident report, investigation reports, initiate Episodic Plan of Care, neuro checks, plan and indicate new fall prevention, if the incident is a fall with injury the Director of Nursing will be notified. The IDT will review the investigation of the fall and the preventive intervention that was put into place. The result of the review will be documented post incident evaluation and the improved intervention will be placed on the residents comprehensive plan of care and added to the tasks on the residents point of care kardex. This deficiency represents non-compliance investigated under Complaint Number OH00131751. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 19 of 36 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 12/21/2022 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 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 observation, review of the medical record and staff interview the facility failed to ensure Resident #42 received her nutritional supplements as ordered. This affected one resident (Resident #42) of four revealed for nutrition. Residents Affected - Few Findings included: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included dementia, generalized anxiety disorder, peripheral vascular disease, congestive heart failure, obsessive compulsive disorder, hypothyroidism, major depressive disorder, and osteoarthritis. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #42 had severely impaired cognition and required extensive assistance of one staff member for eating. She did not have a weight loss. Review of the December 2022 physician orders revealed Resident #42 had an order for a magic cup twice daily with lunch and dinner dated 11/10/22. Observation on 12/13/22 at 5:05 P.M. revealed Personal Care Attendant (PCA)#135 gave Resident #42 her meal in the dining room. Resident #42 received chicken [NAME], red bliss potatoes, peaches, eight ounces of milk, and four ounces of apple juice, however she never received a magic cup with her meal. On 12/13/22 at 5:10 P.M. interview with PCA #135 verified Resident #42 had not received her ordered magic cup for supper. Observation on 12/14/22 at 5:15 P.M. revealed Resident #42 received her meal without receiving a magic cup. On 12/14/22 at 5:15 P.M. interview with State Tested Nursing Assistant #160 verified Resident #42 had not received her ordered magic cup On 12/14/22 at 5:17 P.M. interview with Dietary Aide #141 verified they had forgot to put in on her tray. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 20 of 36 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 12/21/2022 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 - Some 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** 4. Review of Resident #31's record revealed an admission date of 03/15/22. Diagnoses included heart failure, congestive heart failure, and hypertension. Review of Resident #31's December 2022 physician orders, revealed an order, dated 03/16/22, for Digoxin 125 micrograms daily for hypertension. Review of Resident #31's pharmacy recommendation, dated 06/09/22, revealed a recommendation for a Digoxin level to be done. Continued reviewed revealed that the physician accepted and agreed to obtaining the level. Review of Resident #31's lab work revealed she had no evidence of a Digoxin level ever being obtained. Interview on 12/15/22 at 1:12 P.M. the Director of Nursing revealed Resident #31's Digoxin level was never obtained. She confirmed the order was missed. 2. Review of the medical record for Resident #4 revealed an admission date on 03/05/2004. Medical diagnoses included schizoaffective disorder-Bipolar type, major depressive disorder, catatonic schizophrenia, drug induced movement disorder, and Chronic Obstructive Pulmonary Disorder (COPD). Review of the physician orders dated from April 2022 to November 2022 revealed Resident #4 had the following orders: Bupropion (generic for Wellbutrin, an antidepressant) 200 milligrams orally two times a day related to major depressive disorder with a start date on 04/16/22 and a discontinue date on 11/15/22 due to Gradual Dose Reduction (GDR) and Bupropion 150 milligrams one tablet by mouth two times a day related to major depressive disorder with a start date on 11/15/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision from one staff to complete Activities of Daily Living (ADLs). Resident #4 received daily antipsychotic and antidepressant medications with a GDR attempted on 07/26/21. Review of the pharmacy notes dated from 12/2021 to 12/2022 revealed Resident #4 had pharmacy recommendations after review of medications in 04/2022, 07/2022, and 08/2022. Review of the care plan revised on 09/30/20 revealed Resident #4 had potential for mood, psychosocial deficit related to diagnosis of depression and a history of psychiatric diagnoses. Interventions included received antidepressant medication, monitor for adverse side effects of medication, monitor and report to physician any ongoing signs and symptoms of depression unaltered by antidepressant, receives antipsychotic medication, monitor for behavior episodes and interventions attempted every shift and document on flow sheet, and psychiatric consult as indicated. Review of the pharmacy recommendations provided by the facility dated from 12/2021 to 12/2022 revealed there was no pharmacy recommendation provided for Resident #4 for the month of April 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 21 of 36 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 12/21/2022 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 - Some On 07/14/22, there was a recommendation for Resident #4 to attempt a GDR from Bupropion SR 200 milligrams two times a day to Bupropion SR daily. The recommendation was accepted with the following modification to reduce Bupropion (Wellbutrin) SR to 150 milligrams twice a day. The recommendation was signed and dated 11/14/22 (four months after the recommendation was made). On 08/18/22, there was a recommendation for Resident #4 to attempt a GDR from Phenobarb (an antipsychotic medication) 64.8 milligrams at bedtime to Phenobarb 32.4 milligrams at night. The recommendation was contraindicated due to continued use was in accordance with the current standard of practice and a GDR attempt was likely to impair the individual's function or cause psychiatric instability. The recommendation was signed and dated 11/14/22 (three months after the recommendation was made). Interview via email on 12/20/22 at 1:46 P.M. with the Director of Nursing (DON) confirmed there was no pharmacy recommendation found for Resident #4 for the month of April 2022 as indicated in the pharmacy note. The DON also confirmed the pharmacy recommendations for Resident #4 dated in July 2022 and August 2022 were not addressed by the Certified Nurse Practitioner (CNP) until 11/14/22 (three and four months after the recommendations were made). 3. Review of the medical record for Resident #34 revealed an admission date on 02/25/19. Medical diagnoses included unspecified dementia with agitation, major depressive disorder-recurrent, delusional disorders, anxiety disorder, and hallucinations. Review of the physician orders dated from April 2022 to November 2022 revealed Resident #34 had the following orders: Escitalopram (generic for Lexapro, an antidepressant medication) 20 milligrams (mg) give one tablet orally at bedtime for major depressive disorder with a start date on 04/16/22 and a discontinue date on 11/15/22 due to a gradual dose reduction (GDR) and Escitalopram 10 mg give one tablet by mouth one time a day related to major depressive disorder with a start date on 11/15/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and scored a ten out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #34 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #34 received daily antipsychotic and antidepressant medications with a GDR attempted on 05/20/22. Review of the pharmacy notes dated from 12/2021 to 12/2022 revealed there was a pharmacy recommendation for October 2022. Review of the care plan revised 06/23/22 revealed Resident #34 had psychosocial and behavior problems and was on an antidepressant medication. Interventions included administer antidepressant medication as ordered, monitor for adverse effects, monitor and report to physician ongoing signs and symptoms of depression unaltered by antidepressant, psychiatric consult as indicated, and document any side effects observed and mood episodes every shift. Review of the pharmacy recommendation dated 10/13/22 revealed Resident #34 received Escitalopram 20 mg daily since 04/16/22, which exceeded the maximum recommended daily dose of 10 mg daily in those [AGE] years of age and older. The recommendation was made to decrease Escitalopram to 10 mg. The recommendation was accepted, signed and dated 11/14/22 (one month after the recommendation was made). Interview on 12/13/22 at 5:46 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendation for Resident #34 dated 10/13/22 was not addressed until 11/14/22, one month after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 22 of 36 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 12/21/2022 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 recommendation was made. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Psychotropic Medication Use, revised 10/24/22, revealed the policy stated, all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences. Residents Affected - Some Based on medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure evidence of documented rationales for attempted gradual dose reductions for Resident #8, failed to ensure timely response to pharmacy recommendations for Residents #34 and #4's medications, failed to obtain laboratory testing as recommended for Resident #31, and failed to ensure Resident #4 received a pharmacy review every month. This affected four residents (#4, #8, #31, and #34) out of five residents reviewed for unnecessary medications. The census was 51. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/21/20 and the diagnoses of schizo-affective disorder, dementia with behavior disturbances, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition, no hallucinations or delusions, but had physical and verbal behaviors towards others. Review of Resident #8's physician orders from November 2021 revealed he was receiving Paxil 20mg daily, Seroquel 25 mg daily, and Seroquel 50 mg at night. Review of Resident #8's care plan dated 01/27/20 revealed the resident had a cognitive deficit, dementia with behavioral disturbances, he had increased periods of agitation and wandering in the evening and night and is not redirectable, he makes sexual remarks to nurses and has been started on antipsychotic for schizoaffective behavior disorder. Interventions included administer medications as ordered. Review of Resident #8's pharmacy recommendations for 11/02/21 revealed the resident was receiving the antidepressant Paxil 20 mg daily since 05/21/21 and to attempt a gradual dose reduction of the medication. It also stated the resident was receiving Seroquel 25 mg in the morning and 50 mg at night since 05/21/21 and to attempt a gradual dose reduction. The physician responded to both recommendations by declining them, without providing a resident specific rationale. Interview on 12/14/22 at 12:40 P.M. with the Director of Nursing (DON) confirmed the lack of rationale for the two gradual dose reduction recommendations for Resident #8. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 23 of 36 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 12/21/2022 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 the medical record for Resident #4 revealed an admission date on 03/05/2004. Medical diagnoses included schizoaffective disorder-Bipolar type, major depressive disorder, catatonic schizophrenia, drug induced movement disorder, and Chronic Obstructive Pulmonary Disorder (COPD). Review of the physician orders dated from April 2022 to November 2022 revealed Resident #4 had the following orders: Bupropion (generic for Wellbutrin, an antidepressant) 200 milligrams orally two times a day related to major depressive disorder with a start date on 04/16/22 and a discontinue date on 11/15/22 due to Gradual Dose Reduction (GDR) and Bupropion 150 milligrams one tablet by mouth two times a day related to major depressive disorder with a start date on 11/15/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required supervision from one staff to complete Activities of Daily Living (ADLs). Resident #4 received daily antipsychotic and antidepressant medications with a GDR attempted on 07/26/21. Review of the pharmacy notes dated from 12/2021 to 12/2022 revealed Resident #4 had a pharmacy recommendation after review of medications for 07/2022. Review of the care plan revised on 09/30/20 revealed Resident #4 had potential for mood, psychosocial deficit related to diagnosis of depression and a history of psychiatric diagnoses. Interventions included received antidepressant medication, monitor for adverse side effects of medication, monitor and report to physician any ongoing signs and symptoms of depression unaltered by antidepressant, receives antipsychotic medication, monitor for behavior episodes and interventions attempted every shift and document on flow sheet, and psychiatric consult as indicated. On 07/14/22, there was a recommendation for Resident #4 to attempt a GDR from Bupropion SR 200 milligrams two times a day to Bupropion SR daily. The recommendation was accepted with the following modification to reduce Bupropion (Wellbutrin) SR to 150 milligrams twice a day. The recommendation was signed and dated 11/14/22 (four months after the recommendation was made). Review of the Medication Administration Record (MAR) for Resident #4 dated from July 2022 through November 2022 revealed Resident #4 continued to receive Bupropion SR 200 milligrams (mg) twice a day for depression from 07/14/22, when the pharmacy recommendation was made, until 11/15/22, when the pharmacy recommendation was accepted, signed, and dated. Interview via email on 12/20/22 at 1:46 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendation for Resident #4 dated in July 2022 was not addressed by the Certified Nurse Practitioner (CNP) until 11/14/22 (four months after the recommendation was made) and Resident #4 continued to receive the antidepressant medication in a larger than recommended dose. 3. Review of the medical record for Resident #34 revealed an admission date on 02/25/19. Medical diagnoses included unspecified dementia with agitation, major depressive disorder-recurrent, delusional disorders, anxiety disorder, and hallucinations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 24 of 36 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 12/21/2022 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 Review of the physician orders dated from April 2022 to November 2022 revealed Resident #34 had the following orders: Escitalopram (generic for Lexapro, an antidepressant medication) 20 milligrams (mg) give one tablet orally at bedtime for major depressive disorder with a start date on 04/16/22 and a discontinue date on 11/15/22 due to a gradual dose reduction (GDR) and Escitalopram 10 mg give one tablet by mouth one time a day related to major depressive disorder with a start date on 11/15/22. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and scored a ten out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #34 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #34 received daily antipsychotic and antidepressant medications with a GDR attempted on 05/20/22. Review of the pharmacy notes dated from 12/2021 to 12/2022 revealed there was a pharmacy recommendation for October 2022. Review of the care plan revised 06/23/22 revealed Resident #34 had psychosocial and behavior problems and was on an antidepressant medication. Interventions included administer antidepressant medication as ordered, monitor for adverse effects, monitor and report to physician ongoing signs and symptoms of depression unaltered by antidepressant, psychiatric consult as indicated, and document any side effects observed and mood episodes every shift. Review of the pharmacy recommendation dated 10/13/22 revealed Resident #34 received Escitalopram 20 mg daily since 04/16/22, which exceeded the maximum recommended daily dose of 10 mg daily in those [AGE] years of age and older. The recommendation was made to decrease Escitalopram to 10 mg. The recommendation was accepted, signed and dated 11/14/22 (one month after the recommendation was made). Review of the Medication Administration Record (MAR) dated October 2022 and November 2022 revealed Resident #34 received Escitalopram 20 milligrams (mg) daily from 10/13/22 to 11/14/22. Interview on 12/13/22 at 5:46 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendation for Resident #34 dated 10/13/22 was not addressed until 11/14/22, one month after the recommendation was made and Resident #34 continued to receive the antidepressant medication at a dose that exceeded the recommended daily dose. Review of the facility policy, Psychotropic Medication Use, revised 10/24/22, revealed the policy stated, all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences. Based on interview, and record review the facility failed to put in place an end date for Resident #31's as needed anxiety medication, and failed to implement a recommendation to reduce an antidepressant for Residents #4 and #34. This affected three out of six residents reviewed for unnecessary medications (Resident #4, #31, and #34). The facility census was 51. Findings include: 1. Review of Resident #31's record revealed an admission date of 03/15/22. Diagnoses included bipolar disorder, major depressive disorder, and anxiety disorder. Additionally a new diagnosis of hallucinations was added on 03/20/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 25 of 36 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 12/21/2022 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 Review of Resident #31's December 2022 physician orders revealed an order dated 03/16/22 for Hydroxyzine 25 milligrams (mg) by mouth as needed for anxiety four times daily. The order did not identify a duration for the medication. Review of Resident #31's pharmacy recommendation, dated 04/15/22, revealed a recommendation to add a stop date to the resident's Hydroxyzine 25 mg four times a day. The Physician accepted the recommendation on 4/25/22 and stated to continue for 14 days. Continued review revealed the order was never changed. Review on the recommendation, dated 07/14/22, revealed the pharmacist again recommended a stop date for Resident #31's as needed Hydroxyzine 25 mg. The physician declined the recommendation on 07/22/22 without a rational. Review of the recommendation, dated 09/15/22, revealed to add an end date for Resident #31's as needed Hydroxyzine. The recommendation was declined with a rational of it is helpful. Interview on 12/15/22 at 1:12 P.M. the facility's Director of Nursing (DON) confirmed the facility did not timely address pharmacy recommendations and provide rationales for not implementing recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 26 of 36 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 12/21/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, staff interview, review of resident diets, review of the menu and dietary spreadsheet, and facility policy review, the facility failed to follow the pre-planned menu and provide pureed bread to five residents (Residents #1, #16, #28, #33, and #154) who received a pureed diet. The deficient practice affected all five residents (Residents #1, #16, #28, #33, and #154) who received a pureed diet. The facility census was 51. Findings Include: Review of the list of resident diets provided by the facility revealed there were five residents who received a pureed diet, Residents #1, #16, #28, #33, and #154. Review of the pre-planned lunch menu dated 12/14/22 revealed country fried steak, garlic mashed potatoes, sunshine carrots, choice of roll, cinnamon maple apple cake, country gravy, margarine, and coffee or tea was to be served to residents. Review of the dietary spreadsheet dated 12/14/22 revealed for a pureed diet the following should be served: #8 scoop of pureed country fried steak, #8 scoop of garlic mashed potatoes, #10 scoop of pureed sunshine carrots, 2/3 slice of pureed bread, #8 scoop pureed cinnamon maple apple cake, a 2 fluid ounce ladle of country gravy, one margarine, and coffee or tea was to be served to those residents on a pureed diet. Interview on 12/14/22 at 11:16 A.M. with the Dietary Manager #134 confirmed there were not any substitutions for the planned meal and the residents should be served everything on the menu. Observation on 12/14/22 at 12:22 P.M. of a pureed meal being plated by [NAME] #130 revealed there was not any pureed bread placed on the plate or meal tray. Interview on 12/14/22 at 12:51 P.M. with Dietary Manager #134 confirmed [NAME] #130 did not puree any bread for the lunch meal and no pureed bread was served. Interview on 12/14/22 at 1:49 P.M. with Dietitian #201 confirmed the residents on a pureed diet should have received pureed bread or an item with an equivalent nutritional value in order to meet the nutritional needs of the residents. Review of the facility policy, Menus, undated, revealed the policy stated, menus shall be planned in advance and followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 27 of 36 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 12/21/2022 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility policy review, the facility failed to properly date opened food items in the refrigerator, freezer, and dry storage areas. The facility also failed to use proper hand hygiene during lunch meal service. The deficient practices had the potential to affect all 51 residents who resided in the facility as there were not any residents who were on a nothing by mouth (NPO) diet. Findings Include: 1. During the initial tour on 12/12/22 from 10:30 A.M. to 10:39 A.M. with Dietary Manager #134, the following items were observed not properly dated: In the refrigerator: A bag of garnish lettuce, opened and not dated A bag of leaf lettuce, opened and not dated A bag of green peppers, not dated A bag of red peppers, not dated A large plastic uncovered bin of onions, not dated Interview on 12/12/22 at 10:34 A.M. with Dietary Manager #134 confirmed the above findings. In the freezer: A bag of Key [NAME] Blend frozen vegetables, opened with a tie twisted around the bag, not dated A bag of frozen sliced zucchini, opened with a tie twisted around the bag, dated 09/05/22 (three months ago). The vegetables appeared to be freezer burned with ice built up on the slices. Interview on 12/12/22 at 10:35 A.M. with Dietary Manager (DM) #134 confirmed the above findings. DM #134 stated (in reference to the frozen zucchini), that needs to be pitched. DM #134 removed the item from the freezer. In dry storage: A bag of [NAME] bow tie pasta, opened with a twist tie around it, not dated Interview on 12/12/22 at 10:40 A.M. with DM #134 confirmed the above finding. 2. Observation on 12/14/22 from 12:13 P.M. to 12:30 P.M. of [NAME] #130 during lunch meal service revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 28 of 36 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 12/21/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many At 12:13 P.M., [NAME] #130 washed his hands and donned clean disposable blue gloves. With the gloves on, [NAME] #130 held a country fried steak patty on the plate while he cut the steak up with a knife. At 12:16 P.M., with the same gloves on, [NAME] #130 picked up a pot holder from the food prep table and used it to open the steamer. [NAME] #130 retrieved a pan of veal patties from the steamer and placed them on the steam table in a pan. At 12:17 P.M., [NAME] #130 touched another country fried steak patty with gloved hands to move it on the plate. At 12:19 P.M., [NAME] #130 grabbed a thermometer from the food prep table with gloved hands and proceeded to take the temperature of a veal patty. At 12:20 P.M., [NAME] #130 held another country fried steak patty on the plate with gloved hands. The cook's thumb was observed touching the patty. At no time during the observation, did [NAME] #130 change gloves or wash his hands. Interview on 12/14/22 at 12:30 P.M. with Dietary Manager (DM) #134 confirmed the above findings. Review of the facility policy, Date Marking, undated, revealed the policy stated, any ready-to-eat and potentially hazardous foods (PHF) prepared and held in refrigeration for over 24 hours, shall be clearly marked to indicate the date by which the food shall be consumed or discarded. The ready-to-eat PHF, if opened/used more than once, shall be date marked on the first date of use and subsequent uses shall be before the original use by date. Review of the facility policy, Dry Storage and Supplies, undated, revealed the policy stated, opened boxes or cans shall be stored in resealed containers/food bags that are labeled/dated. Review of the facility policy, Frozen Storage, undated, revealed the policy stated, all frozen products shall be labeled indicating product name and date of delivery (month, day, year). Review of the facility policy, Refrigerated Storage, undated, revealed the policy stated, refrigerated items shall bear a label indicating product name and date (month, day, year) product was received, used, or first opened. Review of the facility policy, Hand Washing, undated, revealed the policy stated, employees shall wash their hands and exposed portions of their arms: before working, after eating/drinking, after using tobacco, after touching bare human body parts other than clean hands or arms, after using the restroom, after handling soiled equipment or utensils, when switching between working with raw food and working with read-to-eat food, after using the telephone, after coughing/sneezing, using a handkerchief or disposable tissue, following contact with any unsanitary surfaces (e.g., touching trash cans, hair, opening doors), between handling soiled and clean dishes, after caring for or handling animals, before putting on disposable gloves, before distributing trays/meals to residents, before serving food to residents after collecting soiled plates and food waste. Disposable gloves shall not be substituted for proper hand washing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 29 of 36 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 12/21/2022 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 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, policy review, and staff interview the facility failed to ensure Resident #5 was offered a pneumonia vaccine. This affected one resident (Resident #5) out of five reviewed for immunizations. Residents Affected - Few Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depressive disorder, neuromuscular dysfunction of the bladder, obstructive sleep apnea, anxiety disorder, anemia, asthma, cramps and spasms. Further review of the medical record revealed no evidence the resident was offered or received the pneumonia vaccine. Review of the history and physical dated 04/03/15 revealed Resident #5 was not up to date on her immunization and did not want any vaccines. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition and was offered the pneumonia vaccine and refused. On 12/14/22 at 2:41 P.M. interview with Director of Nursing verified she could not find any documentation Resident #5 had been asked if she wanted the pneumonia vaccine since she was admitted . Review of the undated facility policy, Influenza and Pneumonia Vaccine, revealed the policy ensure all residents or their legal representatives are educated as to the benefits and side effects of receiving the influenza and pneumococcus immunization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 30 of 36 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 12/21/2022 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, resident interviews and staff interviews the facility failed to ensure Resident #153, Resident #201, and Resident #204 received COVID-19 vaccine education. This affected three residents (Resident #153, #201 and #204) of five reviewed for COVID-19 vaccinations. Findings included: 1. Review of the medical record revealed Resident #201 was admitted to the facility on [DATE]. Diagnoses included cellulitis, acute metabolic acidosis, heart failure, diabetes, atrial fibrillation, thyrotoxicois, glaucoma, osteoarthritis, and hypertension. There was no Minimum Data Set (MDS) information available, she had refused the COVID-19 vaccination and there was no documentation COVID-19 vaccination education was given. On 12/14/22 at 10:03 A.M. interview with Resident #201 revealed she had not been given education on the COVID-19 vaccine from the facility. On 12/14/22 at 9:27 A.M. interview with the Director of Nursing (DON) verified the facility did not have documentation they had given education to Resident #201 concerning the COVID-19 vaccinations and they did not have documentation of a consent form for her refusal. On 12/15/22 at 9:51 A.M. interview with the DON revealed when the facility had the COVID-19 vaccine clinic she would go around and ask the residents if they wanted the COVID-19 vaccine and provide information and education. 2. Review of the medical record revealed Resident #153 was admitted to the facility on [DATE]. Diagnoses included acute cystitis, acute bronchitis, acute respiratory failure, transient cerebral ischemic attack, monoclonal gammopathy, major depressive disorder, anxiety disorder, dementia, atrial fibrillation and hypertension. Further review of the medical record revealed she had refused the COVID-19 vaccine and there was no documentation COVID-19 vaccination education was given. Review of the admission MDS assessment dated [DATE] revealed Resident #153 had severely impaired cognition. On 12/15/22 at 9:30 A.M. interview with Resident #153's Family Member revealed he was never given education on the COVID-19 vaccine for his wife (Resident #153). On 12/14/22 at 9:27 A.M. interview with the DON verified the facility did not have documentation they had given education to Resident #153 concerning the COVID-19 vaccinations and they did not have documentation of a consent form for her refusal. On 12/15/22 at 9:51 A.M. interview with the DON revealed when the facility had the COVID-19 vaccine clinic she would go around and ask the residents if they wanted the COVID-19 vaccine and provide information and education. 3. Review of the medical record revealed Resident #204 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 31 of 36 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 12/21/2022 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Diagnoses included cerebral atherosclerosis, Alzheimer's disease, and dementia. There was no MDS assessment information available, he had refused the COVID-19 vaccine and there was no documentation COVID-19 vaccination education was given. On 12/15/22 at 9:38 A.M. interview with Resident #204 revealed he was never given education on the COVID-19 vaccine from the facility. On 12/14/22 at 9:27 A.M. interview with the DON verified the facility did not have documentation they had given education to Resident #204 concerning the COVID-19 vaccinations and they did not have documentation of a consent form for his refusal. On 12/15/22 at 9:51 A.M. interview with the DON revealed when the facility had the COVID-19 vaccine clinic she would go around and ask the residents if they wanted the COVID -19 vaccine and provide information and education. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 32 of 36 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 12/21/2022 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, and facility policy and procedure review, the facility failed to ensure call lights were in working order. This affected one Resident (#103) out of four residents reviewed for accidents, and had the potential to affect 27 residents (#1, #3, #4, #7, #8, #9, #10, #11, #14, #16, #18, #20, #21, #28, #31, #32, #33, #35, #37, #38, #41, #45, #103, #153, #154, #204, #301) who utilized the station #3 shower room. The census was 51. Residents Affected - Some Findings Include: Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 required extensive two staff assistance for transfers and bed mobility and extensive one staff assistance for toileting, personal hygiene, dressing, and bathing. Review of the care plan for Resident #103 dated 11/29/22 revealed the resident had an activities of daily living self care performance deficit related to amputation of second toe on right foot, osteomyelitis, cellulitis, vertigo, dementia and low back pain, he required assistance with bathing, hygiene and dressing and he prefers to have a shower twice weekly. Interventions included staff to set up equipment and assist as needed for bathing, dressing and hygiene and encourage independence. The care plan also stated the resident had an alteration in self mobility, he was at risk for injury from falls related to amputation of second toe on right foot, dementia and impaired balance with interventions to be sure call light is within reach and encourage its assistance, keep in good body alignment, assist with mobility, transfers and ambulation, and anticipate the residents needs. Review of the fall risk assessments dated 11/23/22 and 12/12/22 revealed Resident #103 was high risk for falls. Review of the fall investigation dated 12/12/22, revealed Resident #103 was receiving a shower when he became lethargic and non-responsive, he fell out of the shower chair, abrasions were noted to his forehead and left knee, he was placed back in bed. Related factors were incontinence, confusion/disorientation, being hearing impaired, and acute conditions. The witness statements revealed State Tested Nurse Assistant (STNA) #150 was giving Resident #103 a shower in the station three shower room, she was washing and rinsing the resident off when he went lethargic and would not respond to her. STNA #150 went to the shower room door to yell for assistance and he fell out of the shower chair. Help arrived and they returned the resident to bed, he sustained an abrasion to forehead and left knee, the physician and family were notified. The new intervention was for two staff assistance while in the shower. Review of the Director of Nursing (DON) witness statement revealed she heard STNA #150 holler for assistance in the shower room, when she arrived, the resident was on the floor in front of the shower chair. Respirations were unlabored and the resident was talking, he was rolled to his back with four staff assistance and an assessment was performed, an abrasion was noted to the forehead and left knee. He was assisted back to the shower chair. Neurological checks were initiated and the resident complained of slight discomfort in left knee but denied headache, his knee was cleansed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 33 of 36 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 12/21/2022 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 0919 and dressings were applied. Level of Harm - Minimal harm or potential for actual harm Review of the nurses note dated 12/12/2022 at 10:28 A.M. revealed Resident #103 was receiving a shower, when he became unresponsive and fell out of the shower chair. An abrasion was noted to his forehead and left knee, and the resident denied any pain or discomfort. The residents responsible parties and physician were notified of the incident, he will be continuously monitored and there were no further concerns at that time. Residents Affected - Some Interview on 12/12/22 at 12:47 P.M. with Resident #103 revealed he was in the shower that morning and two staff dropped him in shower. He stated he received an abrasion to the top of his head and he bumped his knee. Interview on 12/14/22 at 11:47 A.M. with Licensed Practical Nurse (LPN) #109 revealed the aide (STNA #150) had Resident #103 in shower and he went unconscious/unresponsive, and went face forward out of shower chair. He received an abrasion on the top of his head and left knee. The physician just said to continue neurological checks and he wasn't too worried. LPN #109 stated STNA #150 should not have left Resident #103 while he was unconscious, but she was too far from a cord and you can't hear anything in the shower room if someone were to yell for help. Interview on 12/14/22 at 11:55 A.M. with STNA #150 revealed she took Resident #103 to the shower in station #3 shower room and he was in a shower chair. As she was washing him up, he went lethargic and he wouldn't respond. She went to the shower door and hollered for help and in the timeframe she left him to go to the door, he fell on the floor. She stated staff showed up to help and assessed him, got him off the floor and got him to his room. She stated he had never gone lethargic like that before and they were talking to him during the incident and he didn't even know or remember that he had fallen. Observation on 12/14/22 at 12:03 P.M. with STNA #150 revealed the station #3 shower room. She pointed that the resident was being showered in the far shower, away from the door, approximately five paces away from the door to the hallway, and a call light was noted on the shower wall. When asked if she could have used the call light in the shower to notify someone of the need for assistance, she stated she didn't even remember there was a call light in the shower room. When asked to see if the call light worked, STNA #150 pulled the call light cord and it was observed that the call light outside of the shower room was not lit up and the call light at the call light board at the nurses station was not lit up. STNA #150 confirmed the call light in the shower did not work. She stated she is glad she didn't try the call light knowing that now. STNA #150 also stated in the past they had used walkie talkies and that would have been helpful had they continued to use them, which they hadn ' t. Interview on 12/14/22 at 12:05 P.M. with STNA #150 and LPN #109 revealed a conversation between the two staff, neither were aware the call light in the shower didn't work and LPN #109 stated she would put in a trouble ticket for that call light. Review of the facility policy and procedure titled, Use of Call Light, undated, revealed the purpose was to respond promptly to the residents call for assistance and to assure a call system was in place and in proper working order. It also stated the emergency call lights should be in functioning order. The policy specifically stated the emergency call lights in bathrooms and shower/tub rooms would have a light and a continuous sound that will appear over the door of the room and on the board at the nurses station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 34 of 36 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 12/21/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain a safe and comfortable environment. This affected all the residents in the facility. The facility census was 51. Findings included: 1. Observations during the initial tour on 12/12/22 from 9:00 A.M. to 9:25 A.M. revealed; a. The carpet was torn by the 100 hall nurses station. b. The wallpaper was torn above the head of the bed in room [ROOM NUMBER]. c. A large area of the wallpaper was torn off the wall under the window. d. The paint was peeling in the corner of the ceiling and was hanging down. e. the wallpaper was torn in hallway by room [ROOM NUMBER]. f. The carpet had numerous large stains in the hallway between the Director of Nursing and Social Service offices, stains in the carpet by room [ROOM NUMBER], stains in the carpet by rooms [ROOM NUMBERS], between rooms 121 and 123, between rooms [ROOM NUMBERS], at double doors outside of room [ROOM NUMBER], outside room [ROOM NUMBER], outside room [ROOM NUMBER], between rooms [ROOM NUMBERS], outside soiled utility room by nurses station on 200 hallway, between rooms [ROOM NUMBERS] and between rooms [ROOM NUMBERS] On 12/13/22 at 9:06 A.M. interview with the Administrator verified it had been a while since the carpet was scrubbed due to their carpet scrubber had been broken and they were using a spot cleaner to scrub the carpet. 2. Observations on 12/13/22 from 4:12 P.M. to 4:23 P.M. revealed wallpaper was peeling in rooms; a. In room [ROOM NUMBER] the wallpaper was missing to the right of the door by the head of the bed. b. In room [ROOM NUMBER] the wallpaper was missing by bed to the left of the door. c. In room [ROOM NUMBER] the wallpaper was missing by sink and trim at the bottom of the wall is broken and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 35 of 36 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 12/21/2022 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 0921 wallpaper was also missing next to the resident's bed. Level of Harm - Minimal harm or potential for actual harm d. In room [ROOM NUMBER] the wall paper was missing by the sink. Residents Affected - Many e. The wallpaper in resident hallway across from room [ROOM NUMBER] by the door that has a sign posted face shield disinfection was peeling. f. The wallpaper was missing behind the picture to the left past room [ROOM NUMBER]. 3. Observation on 12/15/22 at 8:21 A.M. revealed the wallpaper was peeling in the top right corner of the room in room [ROOM NUMBER]. On 12/15/22 at 10:51 A.M. environmental rounds with Maintenance #148, verified all the environmental concerns. He indicated he was not sure what the company's plans were for the carpet and wallpaper issues. This deficiency represents non-compliance investigated under Complaint Number OH00131751. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 36 of 36