Health inspection·December 5, 2023

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On 11/07/23 at 2:00 P.M. Medical Director #520 was updated by the Director of Nursing. Residents Affected - Few On 11/07/23, 3:40 P.M. State Tested Nursing Assistant (STNA) #140 was provided immediate 1:1 education by the DON regarding resident supervision levels. • • On 11/08/23, the process was changed for transportation to pick up residents at the back entrance of the facility. • On 11/08/23 at 9:40 A.M. the Administrator notified the transportation company by telephone of the new process for pick-up of the residents at the facility. • On 11/08/23 and 11/09/23, AD Hoc QAPI meetings were held with the Administrator, the Director of Nursing, and Senior Living President #515 to discuss the action plan items. All items were approved. • On 11/09/23 at 10:00 A.M. Medical Director #520 was updated by the Director of Nursing of the action taken since 11/07/2023 and upcoming in-services of staff. • On 11/09/23, Maintenance Staff #420 and #530 evaluated all wheelchairs and other mobility equipment in the facility for safety and working order. No equipment was identified as not in working order, including the chair utilized by Resident #50 on 11/7/23. • By 11/10/23, [NAME] Data Set (MDS) Registered Nurse (RN) #470 reassessed all 48 residents residing in the facility at the time for updated elopement risks and need for supervision outside of the facility. Residents #17 and #16 were determined to be safe outside of the facility without supervision. • By 11/10/23, The Administrator and the Director of Nursing (DON) in-serviced all 44 staff on the new facility policy and procedure related to transfer and pick up procedures, the elopement policy and procedure and updated elopement risks and residents needing supervision, the abuse and neglect policy and procedure, and wheelchair and equipment maintenance and review of the new process for when malfunctioning equipment is identified by staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 2 of 8 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 12/05/2023 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 - Immediate jeopardy to resident health or safety On 11/16/23 the Quality Assurance Committee met and reviewed the results of the in-services and the updated resident elopement assessments. • Residents Affected - Few On 11/27/23 the DON and designees began random audits of resident equipment and transportation pickups to ensure all equipment was functioning properly and residents were transported and supervised in accordance with their plan of care. The audits will be conducted three times a week for four weeks and then weekly for four weeks. The results of the audits will be reviewed at the end of the month or within the first week of the following month by the Interdisciplinary Team for ongoing compliance. The results of the audits will be reviewed again at the quarterly Quality Assurance Committee meeting. Due to the audit process, equipment that is found to not be working properly will be removed from use until the equipment is working properly. Additional staff education and in-services will occur if concerns are identified with supervision and/or the new transportation process. • On 11/28/23 from 1:10 P.M. through 2:45 P.M. surveyor interviews with RN #400, LPN #395 and STNAs #55, #80, #90, and #130 revealed the staff received in-service/education and were knowledgeable of the new facility policy and procedure related to transfer and pick up, the elopement policy and procedure and updated resident elopement risks and residents needing supervision, the abuse and neglect policy and procedure, and wheelchair and equipment maintenance and review of the new process for when malfunctioning equipment is identified by staff. Although the Immediate Jeopardy was removed on 11/27/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (chemical imbalance in the blood that affects the brain) unspecified dementia, lung cancer, chronic obstructive pulmonary disease, anxiety, and repeated falls. Review of Resident #50's skilled nursing assessment dated [DATE] and completed by RN #490 revealed Resident #50 used a wheelchair for mobility during transport to appointments and while out of the facility with family. Review of Resident #50's care plan initiated on 10/11/23 revealed Resident #50 was at risk for falls related to the diagnoses of dementia, anxiety, fibromyalgia, and history of falls. Interventions were implemented including monitor resident for changes in ambulation and assist with bed mobility, transfers and ambulation as needed. Further review revealed Resident #50 had cognitive deficit which put Resident #50 at risk for wandering and elopement. The intervention for the use of a wander guard was implemented on 10/20/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 3 of 8 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 12/05/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #50's quarterly [NAME] Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had impaired cognition, used a walker for independent ambulation assistance, required extensive assistance from one to two staff members for transfers, bed mobility and toilet use. Resident #50 was receiving speech therapy, occupational therapy, and physical therapy to improve strength, coordination, and cognition. Review of Resident #50's fall risk screen assessment dated [DATE] completed by RN #400 revealed Resident #50 was identified as a high risk for falls with a score of 12. Review of Resident #50's wandering/elopement risk assessment dated [DATE] and completed by LPN #375 revealed Resident #50 was at high risk for wandering related to history of wandering and impaired cognition. The intervention for placement of a wander guard (a bracelet that residents wear that will alert staff if the resident approaches a monitored exit door) was implemented on 10/20/23. Review of Resident #50's physician orders listing for November 2023 revealed signed physician orders dated 10/20/23 for placement check of a wander guard to Resident #50's right ankle was to be completed every shift and to check function of the wander guard to be completed on every night shift. Review of Resident #50's nurse progress notes dated 11/07/23 at 1:00 P.M. and authored by RN #400 revealed Resident #50 was observed lying face down on the sidewalk and grass at the base of six concrete steps at the front of the facility. Resident #50 had skin tears to bilateral hands and a hematoma with abrasion was noted above the right temple. Resident #50 was alert but could not respond appropriately to questions. Review of Resident #50's nurse progress notes dated 11/07/23 at 1:51 P.M. and authored by LPN #375 revealed LPN #375 was called outside by a State Tested Nursing Assistant (STNA) (not identified in the progress note) due to Resident #50 falling out of the wheelchair and down the first flight of concrete stairs. Resident #50 was alert but could not respond appropriately to orientation questions. Resident #50's fall was witnessed by a therapy staff member leaving the facility for the day. Review of the Emergency Medical Services (EMS) Patient Care Record dated 11/07/23 at 1:05 P.M. revealed Resident #50 was observed lying on her back with facility staff securing Resident #50's head and neck. Resident #50 was noted to be looking around but was unable to answer questions appropriately or follow verbal commands. EMS notified the medical helicopter service for transport of Resident #50 due to her age and mechanism of injury. EMS transported Resident #50 to the emergency room for further evaluation. Review of Resident #50's hospital emergency room progress notes dated 11/07/23 at 1:30 P.M. revealed the results of Resident #50's head Computed Tomography (CT) of acute right frontal and temporal lobe parenchymal hemorrhage (bleeding from ruptured blood vessels into the parenchyma or functioning tissue of the brain), a small right subdural hematoma (occurs when blood vessels rupture between the skull and the brain (subdural space) is damaged. Blood escapes from the blood vessel, leading to the formation of a blood clot (hematoma) that places pressure on the brain and damages the brain) with no significant mass effect of midline shift of the brain. Resident #50 was noted to be able to follow commands, open eyes, but was confused. Resident #50's airway was intact. Resident #50 was transferred via medical helicopter to a higher-level trauma center. As part of the facility investigation, incident report, post incident evaluation, and staff statements were obtained which revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 4 of 8 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 12/05/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Accident/Incident Report completed by the DON dated 11/07/23 revealed Resident #50 had been leaving the facility for an appointment when she was left unattended outside the facility and fell down the front steps with the wheelchair. Resident #50 was unable to respond to the DON concerning Resident #50's activity prior to the fall. Resident #50's status and related factors were marked as confused/disoriented, the use of psychotropic, cardiac, and high blood pressure medications and the use of mobility devices including a walker and wheelchair. Notifications were completed for the responsible party, the physician, and the DON. Resident #50 was transported to the emergency room by the emergency medical services (EMS) with injuries noted as hematoma to the right temple and skin tears to bilateral hands. Review of the Post Incident Evaluation completed by the Director of Nursing (DON) on 11/07/23 revealed the location of Resident #50's fall was the front steps of the facility. The injuries sustained were hematoma to the right temple and skin tears to both hands. Physical Therapist Assistant (PTA) #525 witnessed the incident. The Medical Director #520 and responsible party were notified by Licensed Practical Nurse (LPN) #375. There were no alarms or restraints in place at the time of the fall. Review of State Tested Nursing Assistant (STNA) #140 statement dated 11/07/23 revealed STNA #140 had wheeled Resident #50 out the front doors of the facility to the porch area for transportation to an appointment. Transportation Personnel #500 requested a different wheelchair due to the brakes not locking on Resident #50's wheelchair and the need for footrests on the wheelchair for transportation of the resident. STNA #140 returned inside the facility to get a different wheelchair for the resident, leaving Resident #50 outside with Transportation Personnel #500. STNA #140 was inside the facility for approximately three to five minutes when Transportation Personnel #500 entered the facility leaving Resident #50 unattended outside of the facility. STNA #140 was exiting the facility with a different wheelchair, when Transportation Personnel #500 notified her, a nurse was needed outside. STNA #140 yelled for a nurse and then exited the facility. STNA #140 observed Resident #50 lying face down with her arms at her sides on the landing at the bottom of the first set of stairs with Physical Therapy Assistant (PTA) #525 at her side with the wheelchair sitting upright to the side of Resident #50. Review of Licensed Practical Nurse (LPN) #375 statement dated 11/07/23 revealed LPN #375 responded to the request of a nurse required outside in front of the facility. LPN #375 observed Resident #50 lying on her back with RN #400, STNA #140 and the Director of Nursing (DON) kneeling beside her. RN #400 was calling emergency medical services. At approximately 1:15 P.M. LPN #375 notified Resident #50's son concerning the incident. At 3:30 P.M. LPN #375 called [NAME] Community Hospital for an update on Resident #50. LPN #375 was notified Resident #50 was air lifted to a trauma center. Review of Registered Nurse (RN) #400 statement dated 11/07/23 revealed RN #400 heard STNA #140 shouting from the front doors that a nurse was needed out front. Upon exiting the building, RN #400 observed the transportation vehicle with the driver standing beside the van. RN #400 ran down the steps and observed Resident #50 lying face down on the landing at the bottom of the first set (of steps) with the wheelchair a few feet away. RN #400 noted Resident #50 had a pulse with her eyes rolled back and shallow, slow respirations were observed. Resident #50 did not verbally respond to RN #400. RN #400 promptly called 911 for emergency medical services (EMS). RN #400, the DON, LPN #375 and STNA #140 assisted in log rolling Resident #50 onto her back. EMS arrived and transported Resident #50 to the emergency room. Review of Physical Therapy Assistant (PTA) #525 statement dated 11/07/23 revealed PTA #525 was pulling her vehicle around to leave the facility when she noticed Resident #50 rolling across the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 5 of 8 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 12/05/2023 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 - Immediate jeopardy to resident health or safety driveway. She put her vehicle into park and got out and ran towards Resident #50 in an attempt to stop the wheelchair. PTA #525 witnessed Resident #50 being ejected from the wheelchair and flew down the steps landing face down on the concrete landing. PTA #525 removed the wheelchair from on top of Resident #50 and placed the wheelchair to the side of Resident #50 activating the brakes to secure the wheels from rolling. Transportation Personnel #500 stated he would go get help and then nursing came out and took over her care. PTA #525 assisted in log rolling Resident #50 to her back. Residents Affected - Few On 11/21/23 at 2:27 P.M. an interview with Registered Nurse (RN) #400 revealed on 11/07/23 State Tested Nursing Assistant (STNA) #140 notified her there was a situation outside in the front of the facility and a nurse was required. Upon exiting the facility through the front doors, Resident #50 was observed lying face down on the landing at the bottom of the first flight of stairs, there was a manual wheelchair sitting upright to the side of where Resident #50 was lying. Physical Therapy Assistant (PTA) #525 was observed kneeling beside Resident #50. Transportation Personnel #500 was observed standing near the transportation van. RN #400 assessed Resident #50 for injuries and noted bleeding from skin tears to Resident #50's hands. RN #400 observed Resident #50 was not responding to verbal stimuli and Resident #50's eyes were noted to be rolled back. Resident #50 was log rolled to her back by the RN #400, therapy staff #525, and the Director of Nursing (DON) for further injury assessment. RN #400 observed a hematoma with abrasion located above Resident #50's right temple. Emergency medical services (EMS) were notified, arrived at the facility, and transported Resident #50 to the emergency room. LPN #375 notified Resident #50's son and notified the medical director concerning the incident. On 11/21/23 at 2:41 P.M. an interview with Licensed Practical Nurse (LPN) #375 revealed Resident #50's cognitive baseline was orientated with intermittent confusion; Resident #50 was independent with ambulation using a walker throughout the facility with impaired safety awareness. Resident #50 had recently started using a manual wheelchair for transportation and longer distance mobility. Resident #50 had been on her assigned hallway for 11/07/23 and had a cardiologist appointment requiring transportation. STNA #140 had gotten Resident #50 ready and placed in a manual wheelchair and then had taken Resident #50 to the front porch area for pick up by the transportation company. LPN #375 was notified of an accident involving Resident #50 outside in front of the facility. LPN #375 went out the front doors of the facility and observed RN #400, STNA #140, the DON, and Physical Therapy Assistant (PTA) #525 kneeling beside Resident #50 who was lying on her back on the landing at the bottom of the first flight of stairs at the front of the facility. LPN #375 observed a hematoma above the right temple and skin tears on both hands. Resident #50 was alert but not responding verbally to LPN #375. RN #400 notified the emergency medical services (EMS) for transportation of Resident #50 to the emergency room. On 11/21/23 at 3:32 P.M. an interview with State Tested Nursing Assistant (STNA) #140 revealed on 11/07/23 Resident #50 had been assisted into a manual wheelchair and escorted to the front of the facility by STNA #140 for transportation to a physician's appointment via a transportation company's van. When STNA #140 had taken Resident #50 out the front doors to the covered porch area, Transportation Personnel #500 inspected Resident #50's manual wheelchair and stated to STNA #140 the wheelchair brakes did not lock and the wheelchair needed to have footrests in place for transport. STNA #140 left Resident #50 sitting outside in the porch area and returned inside the facility to get a different wheelchair for Resident #50. STNA #140 was in the facility for approximately 3-5 minutes when Transportation Personnel #500 entered the facility to assist STNA #140 in finding a replacement wheelchair for Resident #50. Transportation Personnel #500 then went back outside, as STNA #140 was pushing the replacement wheelchair out the first set of front doors, Transportation Personnel #500 came in the first set of doors and told STNA #140 to get a nurse to come outside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 6 of 8 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 12/05/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few STNA #140 notified Registered Nurse (RN) #400 concerning an accident outside in the front of the facility. STNA #140 and RN #400 went out the front doors and crossed the driveway where Resident #50 was observed lying face down on the landing at the bottom of the first flight of concrete stairs. PTA #525 was observed with Resident #50 and Resident #50's wheelchair was noted to be sitting upright to the side of where Resident #50 was located. On 11/22/23 at 9:02 A.M. an interview with PTA #525 revealed on 11/07/23 at approximately 1:10 P.M. she was leaving the facility for the day. As PTA #525 was driving her vehicle up and around the corner of the driveway she observed Resident #50 sitting in a manual wheelchair freewheeling across the driveway towards the first set of stairs leading down to the parking lot. PTA #525 attempted to put her vehicle in park and exit the vehicle to stop Resident #50 from falling down the stairs, but PTA #525 wasn't able to fast enough and witnessed Resident #50 front wheels of the manual wheelchair go over the edge of the first step causing Resident #50 to be ejected from the seat of the manual wheelchair and fall down the remaining set of stairs ending up face down to the right side of the concrete landing with the manual wheelchair laying on top of Resident #50. Transportation Personnel #500 was observed walking across the driveway towards the set of steps talking on his cell phone. PTA #525 requested Transportation Personnel #500 to get a nurse from inside of the facility. RN #400 and the Director of Nursing (DON) was observed exiting the building. PTA #525 removed the manual wheelchair from atop Resident #50 and placed the manual wheelchair to the side of where Resident #50 was located on the stairs landing. PTA #525 applied the brakes to the wheelchair locking the wheels in place. PTA #525 assisted RN #400 and the DON in log rolling Resident #50 onto her back for airway protection and further injury assessment. On 11/22/23 at 9:37 A.M. an interview with the Director of Nursing (DON) revealed Resident #50 was alert with periods of intermittent confusion with occasional hallucinations. Resident #50 was independent with ambulation using a walker for assistance. Resident #50 had a wander guard in place due to wandering behavior. On 11/07/23 at approximately 1:10 P.M. the DON was notified of an accident involving Resident #50 outside in front of the facility. The DON observed Resident #50 lying face down on the landing at the bottom of the first set of steps leading down to the parking lot. PTA #525 was kneeling beside Resident #50 and Resident #50's wheelchair was sitting upright to the side of where the resident was located. The DON assisted in log rolling Resident #50 onto her back for airway protection and further injury assessment. Transportation personnel #500 was observed standing near the transportation van in front of the facility. The DON observed a hematoma above the right temple area and skin tears on both hands of Resident #50. RN #400 notified EMS and requested transport to the emergency room for further evaluation of Resident #50. On 11/24/23 at 9:45 A.M. an interview with the Medical Director #520 revealed he had been notified of the accident involving Resident #50 and had given the order for transport of Resident #50 to the emergency room for further evaluation. On 11/28/23 at 11:15 A.M. an interview with the Director of Nursing (DON) revealed during the interdisciplinary team investigation, there were several factors involved with Resident #50's accident and fall. The DON stated the resident should not have been left unattended outside of the facility. On 11/30/23 at 10:05 A.M. an interview with Medical Director #520 revealed he had attended the Quality Assurance Committee meeting on 11/16/23 and reviewed the results of the in-services and the updated resident elopement assessments. The medical director did not provide any additional information related to the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 7 of 8 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 12/05/2023 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 Several calls were made to the transportation company, but no return calls were provided. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility's policy titled, Fall prevention and Management Policy and Procedure dated 04/2021 revealed Each resident will be assessed for fall risk during the admission process. A plan of care based on identified risk factors will be implemented. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00148435. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 8 of 8