Health inspection·February 20, 2025

F 0561 least twice a week. The DON verified Resident #47 had not received a shower in the last 30 days. Level of Harm - Minimal harm or potential for actual harm 2 Review of the medical record for Resident #30 revealed an admission date 11/30/24. Diagnosis included chronic kidney disease stage 3, atrial fibrillation and muscle weakness. Residents Affected - Some Review of the admission MDS dated [DATE] revealed Resident #30 had intact cognition. Under preferences revealed choosing between a tub bath, shower, bed bath or sponge bath is very important. Review of the plan of care dated 12/30/24 revealed Resident #30 had an activity of daily living (ADL's) performance deficit. requiring assistance with bathing, hygiene and dressing. Interventions included staff to set up equipment and assist as needed for bathing, dressing and hygiene. Review of the task tab in the medical records revealed Resident #30's bathing needs were on Tuesday and Friday, on evening shift with one assist of staff. Review of the progress notes from 11/30/24 revealed no progress note on refusing showers. Review of the shower log from 01/21/25 through 02/19/25 revealed Resident #30 received bed baths on 01/21/25, 01/22/25, 01/25/25, 01/26/25, 01/27/25, 01/29/25, 01/31/25, 02/04/25, 02/06/25, 02/0825, 02/09/25, 02/13/25, 02/14/25, 02/17/25 and 02/18/25. Resident #30 received a shower once on 02/07/25. Interview on 02/18/25 at 1:04 P.M. with Resident #30 revealed he is not getting showers like he wants, once or twice a week would be nice. Staff will wash him but that is all and they want to come in at 10:30 P.M. to give him a bath and that is too late. Interview on 02/19/25 at 3:00 P.M. with the DON verified Resident #30 did not receive showers according to Resident #30's preference. Residents should be receiving showers at least twice a week. The DON verified Resident #30 only received a shower once in the last month. 3 Review of the medical record for Resident #26 revealed an admission date 06/01/24. Diagnosis included anxiety, dementia and chronic obstructive pulmonary disease. Review of the annual MDS dated [DATE] revealed Resident #26 had intact cognition. Under preferences Resident #26 showed it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of the care plan dated 06/17/24 revealed Resident #26 required assistance for bathing related to impaired mobility and weakness. Interventions included one assist for bathing. prefer showers and ensure hair is washed and nails are manicured on bathing day. Review of the shower log from 01/21/25 through 02/19/25 revealed a bed bath on 01/21/25, 01/22/25, 01/23/25, 01/26/25, 01/27/25, 01/28/25, 01/31/25, 02/04/25, 02/05/25, 02/06/25, 02/08/25, 02/09/25, 02/10/25, 02/12/25, 02/13/25, 02/14/25, 02/17/25 and 02/18/25. Showers were given on 01/22/25, 01/29/25 and 02/12/25. Shower /bath skin sheet for 01/22/25 and 01/29/25 skin check completed. Interview on 02/18/25 at 1:17 P.M. with Resident #26 revealed she gets a shower at night and would like to receive a shower at least once a week. Resident #26 stated she asked for her showers to be moved to days and this has not happened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 2 of 12 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 02/20/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/19/25 at 3:00 P.M. with the DON verified Resident #26 did not receive showers according to Resident #26's preference and some residents should be receiving showers at least twice a week. The DON verified Resident #26 received three showers in the last 30 days. 4. Review of Resident #19's medical record revealed an admission date of 12/28/23 with diagnoses including but not limited to hemiplegia on the left side, anxiety, depression and history of stroke. Resident #19 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 dated 01/04/25. Resident #19 required assistance from staff to complete activities of daily living (ADL) tasks including transfers, bathing/showering and personal hygiene tasks related to left side weakness and hemiplegia. Review of Resident #19's ADL care plan dated 01/03/24 revealed Resident #19 required staff assistance for bathing, personal hygiene, shaving, dressing and toileting with intervention marked as bathing with shower days on Monday and Fridays during evening shift. Review of Resident #19's of Annual [NAME] Data Set (MDS) dated [DATE] revealed Section F Preferences for Routine and Activities revealed for Resident #19 the choice of showering was very important. Further review revealed in Section GG - Functional Abilities Resident #19's assistance level for showering marked as maximum assistance from staff with personal hygiene assistance marked as supervision assistance by staff. Review of Resident #19's Point of Care (POC) task documentation dated 01/25/25 to 02/17/25 revealed there were no showers being completed during the timeframe; bed baths were marked as being completed instead and there were no refusals marked. Further review of Resident #19's shower sheets dated 01/17/25, 01/20/25, 01/24/25, 01/28/25, 01/31/25, 02/10/25, and 02/07/25 revealed bed baths were completed on these dates. An interview on 02/18/25 at 12:10 P.M. with Resident #19 revealed he had not been receiving regular showers on Monday and Friday nights. Resident #19 stated he preferred to have showers two times a week and not bed baths. An interview on 02/19/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #19 was not receiving showers as he preferred. The DON stated residents should be receiving showers per their preference and not at the convenience of the staff. 5. Review of Resident #21's medical record revealed an admission date of 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Resident #21 had moderately impaired cognition and required assistance with completion of ADL tasks including transfers, bathing/showering, and personal hygiene. Review of Resident #21's ADL care plan dated 10/21/24 revealed Resident #21 received assistance with bathing/showering with preferred showers marked as Sunday and Thursday's during evening shift. Review of Resident #21's quarterly MDS dated [DATE] revealed Section F - Preferences for Routine and Activities revealed for Resident #21 the choice of showering was very important. Further review revealed in Section GG - Functional Abilities Resident #21's assistance level for showering and personal hygiene marked as supervision assistance from staff. Review of Resident #21's POC shower/bathing documentation dated 01/25/25 to 02/17/25 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 3 of 12 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 02/20/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some showers being received on 01/25/25 and 02/08/25, bed baths being received on 01/23/25, 01/24/25, 01/31/25, 02/03/25, 02/07/25, 02/09/25, 02/21/25, 02/13/25, 02/14/25 and 02/17/25, and not applicable (NA) being marked on 01/26/25, 01/29/25, and 02/02/25. Interview on 02/18/25 at 10:55 A.M. with Resident #21 revealed their last shower was received on Saturday 02/08/25. Resident #21 stated, at best, he may get one shower a week and sometimes there is no shower offered, only a bed bath. Resident #21 preferred to have two showers per week. An interview on 02/19/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #21 was not receiving showers as he preferred. The DON stated residents should be receiving showers per their preference and not at the convenience of the staff. 6. Review of Resident #43's medical record revealed an admission date of 12/06/24 with the following diagnoses including but not limited to weakness, anxiety, major depression, and high blood pressure. Resident #43 was cognitively intact dated 12/13/24. Resident #43 required assistance from staff to complete ADL tasks including bathing/showers and personal hygiene. Review of Resident #43's admission MDS dated [DATE] revealed the resident was cognitively intact and required assistance from staff to complete ADL tasks including bathing/showers and personal hygiene. Section F - Preferences for Routine and Activities revealed for Resident #43 the choice of showering was very important. Further review revealed in Section GG - Functional Abilities Resident #43's assistance level for showering and personal hygiene marked as partial to moderate assistance from staff. Review of Resident #43's ADL care plan revision date 02/01/25 revealed assistance with bathing/showering as an intervention, there were no preferences documented for Resident #43. Review of Resident #43's POC task documentation dated 01/25/5 to 02/17/25 revealed Resident #43's preference for shower days as being on Mondays and Thursdays during day shift. There was a shower marked as being completed on 01/25/25 and a tub bath as being completed on 01/26/25. The rest of the dates were marked as having a bed bath being completed. Interview on 02/18/25 at 10:53 A.M. with Resident #43 revealed she had only been receiving a shower or bed bath once a week and would prefer to have two showers per week. An interview on 02/19/25 at 3:15 P.M. with the Director of Nursing (DON) confirmed Resident #43 was not receiving showers as she preferred. The DON stated residents should be receiving showers per their preference and not at the convenience of the staff. Review of the facility's policy titled, Personal Hygiene, Bathing and Showering of the Residents undated revealed, Nursing facilities shall provide residents with the opportunity for bathing per the resident's preference. The resident, the family, or an alternate decision maker shall have the opportunity to choose a type of bathing method that is preferred. In addition, the resident has an opportunity to express how often they would like to bath as well as what time of the day they prefer (am, pm). Review of the facility policy Personal Cleanliness/hygiene, dated 02/19/25 revealed personal cleanliness/ hygiene is the foundation for health and wellness. The nursing facilities shall provide residents with the opportunity for bathing per the resident's preference. personal hygiene, bathing and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 4 of 12 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 02/20/2025 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 showering of the residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 5 of 12 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 02/20/2025 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 medical record review, observations, interviews, and facility policy review the facility failed to ensure fall/safety measures were in place for a high fall risk resident. This deficient practice affected one resident (Resident #19) of four residents reviewed for accidents and hazards. The facility census was 53. Findings Include: Review of Resident #19's medical record revealed admission date 12/28/23 with diagnoses including but not limited to Parkinson's Disease, hemiplegia on the left side, anxiety, depression and history of stroke. Review of Resident #19's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 dated 01/04/25. Resident #19 required assistance from staff to complete activities of daily living (ADL) tasks including transfers, bathing/showering and personal hygiene tasks related to left side weakness and hemiplegia. Review of Section J - Health Conditions revealed two or more falls were marked as occurring since admission. Review of Resident #19's fall risk assessment dated [DATE] revealed Resident #19 score was 16 which placed him in a high risk category for falls. Review of Resident #19's self mobility care plan revised date 01/13/25 revealed fall interventions including but not limited to pad alarm to wheelchair and bed to alert (staff) of unassisted transfers, a mirror and table outside of the bathroom, and appropriate footwear in place. Review of Resident #19's signed physician orders revealed an order dated 01/14/25 for a pad alarm to the wheelchair to notify staff of unassisted transfers, every day and night shift. There was no order for the pad alarm to be used in Resident #19's bed. Review of Resident #19's Treatment Administration Record (TAR) dated 01/15/25 to 02/19/25 revealed completion of monitoring the pad alarm to Resident #19's wheelchair seat during both day and night shifts. An observation on 02/18/25 at 12:11 P.M. revealed Resident #19 was in his room, seated in his wheelchair. There was a pad alarm located on the bed but no pad alarm in the wheelchair. An observation on 02/19/25 at 11:32 A.M. revealed Resident #19 was self propelling in the wheelchair in the hallway, and there was no pad alarm in the wheelchair. An observation on 02/19/25 5:21 P.M. revealed Resident #19 was in the dining room, sitting in the wheelchair at the table waiting for the supper meal. There was no pad alarm in the wheelchair. An interview on 02/19/25 at 5:23 P.M. with Certified Nursing Assistant (CNA) #315 confirmed there was no pad alarm in Resident #19's wheelchair. CNA #315 shared they thought the pad alarm was only for the resident's bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 6 of 12 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 02/20/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete An interview on 02/19/25 at 5:25 P.M. with the Assistant Director of Nursing (ADON) verified the pad alarm for Resident #19 should be in both the wheelchair and the bed to alert staff of Resident #19's attempted unassisted transfers. Review of the facility's policy titled, Fall Prevention and Management Policy and Procedure revised 04/2021 revealed, The Interdisciplinary Team (IDT) will review the investigation of the fall and the preventative intervention that was put into place. The results of the review will be documented on the Post Incident Evaluation and the approved intervention will be placed on the resident's comprehensive plan of care and added to the tasks on the resident's Point of Care [NAME]. Event ID: Facility ID: 365269 If continuation sheet Page 7 of 12 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 02/20/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review the facility failed to implement indwelling urinary catheter care orders. This deficient practice affected one resident (Resident #21) of two residents reviewed for urinary catheter care. The facility census was 53. Findings Include: Review of Resident #21's medical record revealed admission date 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Review of Resident #21's urinary catheter care plan dated 06/02/23 revealed Resident #21 had a suprapubic indwelling urinary catheter with interventions including catheter care every shift. Review of Resident #21's signed physician orders revealed an order dated 01/01/25 to change #20 french/10 milliliter (ML) Supraprubic catheter with plug every day shift every 29 days for maintenance, last changed on 12/01/24 and an order dated 02/14/25 to flush the catheter every day shift until clear discharge for sediment. There were no orders for daily indwelling urinary catheter care and/or monitoring the insertion site. Review of Resident #21's treatment administration record (TAR) dated 01/01/25 to 02/19/25 revealed no orders for indwelling urinary catheter care and no orders for monitoring insertion site. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed moderately impaired cognition with a BIMS score of 10 out of possible 15. Resident #21 required assistance with completion of activities of daily living tasks including transfers, bathing/showering, personal hygiene, and had an indwelling urinary catheter. An interview on 02/20/25 at 11:35 A.M. with the Director of Nursing (DON) confirmed there were no indwelling urinary catheter care orders implemented for Resident #21 and there were no orders to monitor the insertion site of the suprapubic indwelling urinary catheter for Resident #21. Review of the facility's policy titled, Infection Control - Indwelling Catheter Care undated revealed, It is the policy of this facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 8 of 12 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 02/20/2025 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. Based on observation, policy review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The census was 53. Finds Included: Observation on 02/18/25 at 8:37 A.M. of the kitchen with the Dietary Manager #300 revealed serving pans of various sizes were being stored wet. There were six serving pans stacked on the shelf that were still wet. Interview on 02/18/25 at 8:40 A.M. with the Dietary Manager #300 verified after serving dishes are washed they have to be air dried completely before being stacked and put away. Review of the facility policy Cleaning Dishes/Dish Machine, dated 2023 revealed dishes should be air dried on the dish racks, not dried with towels. Dishes are to be inspected for cleanliness and dryness and put dishes away. Dishes should not be nested unless they are completely dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 9 of 12 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 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. Observation on 02/20/25 at 2:20 P.M. revealed Housekeeper #337 cleaning a resident's room. The resident was in isolation for Clostridium Difficile (C-diff) (a very contagious infection that causes diarrhea and inflammation of the colon). Observed on the housekeeping cart was several cleaning supplies. Residents Affected - Many Interview on 02/20/25 at 2:22 P.M. with Housekeeper #337 stated she was trained to use Clorox Clean-Up Disinfectant with Bleach to clean resident rooms with C. diff. Observation of the bottle efficacy label did not list C. diff as a bacteria that it was effective against. Interview on 02/20/25 at 3:15 P.M. with Housekeeping Supervisor #240 confirmed she investigated the product and it does not kill the bacteria C. Diff. She reported it had been awhile since they had a case but when they did she instructed staff members to use bleach or the Clorox Clean-Up Disinfectant with Bleach. She verified she would need to retrain staff and order additional cleaning supplies that will kill the bacteria. Interview on 02/20/25 at 3:20 P.M. with Registered Nurse #254, who identified herself as the infection control nurse, verified the facility did not have an outbreak of C. diff. She stated the facility would retrain the housekeeping staff on appropriate cleaning agents to use that will be effective against killing the bacteria. Based on observation, water management plan review and interview, the facility failed to maintain a comprehensive water management plan and utilize appropriate disinfectants to prevent the spread of communicable disease. This had the potential to affect all residents who reside in the facility. The facility census was 53. Findings include: 1. Review of the undated Water Management Plan revealed it was not descriptive of the facility. The plan did not detail limits or control measures. The Water Management Plan excluded the basement and fixtures such as the backflow prevention device in the Water Management Plan flow diagrams. Review of the empty room water temperature checks revealed the water temperature checks were not completed in January, March, and April of 2024. Interview on 02/20/25 at 3:15 P.M. with the Administrator revealed the Water Management Plan is a template and in development. The Administrator revealed he would have it completed in the next month. The Administrator also revealed the minimum water temperature they test for is not indicated in the Water Management Plan. The Administrator revealed the basement floor plan is not included in the Water Management Plan flow diagrams. The Administrator confirmed that empty room water checks were missed in some months last year. Review of the Worksheet to Identify Buildings at Increased Risk for Legionella Growth and Spread dated 09/26/24 revealed the facility water safety plan or Legionella prevention program was in progress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 10 of 12 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 02/20/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, interview and facility policy review the facility failed to obtain urinary testing prior to administration of an antibiotic medication for a possible urinary tract infection and failed to complete criteria for the use of an antibiotic medication. This deficient practice affected one resident (Resident #21) of two residents reviewed for antibiotic medication use. The census was 53. Residents Affected - Few Findings Include: Review of Resident #21's medical record revealed admission date 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Resident #19 had moderately impaired cognition with a BIMS score of 10 out of possible 15 dated 01/20/25. Resident #21 required assistance with completion of ADL tasks including transfers, bathing/showering, personal hygiene, and had an indwelling urinary catheter. Review of Resident #21's signed physician orders dated 02/01/25 to 02/19/25 revealed an order dated 02/13/25 for antibiotic medication Amoxicillin oral tablet 500 milligram (MG) give one tablet by mouth three times a day for a urinary tract infection until 02/20/25. There were no orders to obtain a urine sample for urinary laboratory testing and culture/sensitivity to accurately prescribe the appropriate antibiotic based on the bacteria identified in the resident's urine specimen Review of Resident #21's medical record revealed there was no assessment to determine if the use of an antibiotic was appropriate before the antibiotic was administered. Review of Resident #21's progress notes dated 02/12/25 at 4:43 P.M. authored Licensed Practical Nurse (LPN) #244 revealed the nurse had attempted to collect a urine sample from Resident #21 due to complaints of flank pain but was unable to do so. LPN #244 flushed Resident #21's catheter with 60 milliliters (ml) of normal saline and returned a thick yellow colored discharge with a foul odor noted from the catheter. The physician was notified. Further review of Resident #21's progress notes reveal a progress note dated 02/13/25 at 12:56 P.M. authored by LPN #244 revealed the physician was in to see Resident #21 regarding his flank pain with new orders for Amoxicillin 500 mg three times per day for 7 days for UTI and flush catheter with 50 ml normal saline daily until clear. Interview on 02/20/25 at 11:15 A.M. with the Assistant Director of Nursing (ADON) confirmed there was no assessment completed to determine if Resident #21's urinary symptoms met criteria for a UTI and warranted treatment with an antibiotic. In addition, there had been only one attempt to obtain a urine sample for laboratory testing for Resident #21's reported flank pain and foul smelling discharge from the indwelling catheter. There were no further attempts to obtain a urine sample. The ADON stated there should have been a culture and sensitivy laboratory test completed so that the most effective antibiotic medication could be ordered for Resident #21. Review of the facility's policy titled, Infection Control - Indwelling Catheter Care undated revealed, It is the policy of this facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 11 of 12 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 02/20/2025 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 Based on record review, staff interview, and policy review the facility failed to ensure Resident #9 and Resident #17, received education regarding the benefits and potential side effects of the the influenza vaccination. This affected two residents (Resident #9 and #17) of five residents reviewed for vaccinations. The facility census was 52. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #9 revealed an admission date of 02/02/23. Diagnoses included unspecified dementia, schizophrenia, and peripheral vascular disease. Review of Resident #9's Immunization Audit Report revealed the resident refused the influenza vaccine on 02/17/23 and education was not provided. The report did not show evidence the resident was offered the vaccine in 2024 or 2025. 2. Review of the medical record for Resident #17 revealed an admission date of 12/01/24. Diagnoses included peripheral vascular disease, diabetes mellitus, and anxiety disorder. Review of Resident #17's Immunization Audit Report revealed the resident was never offered the influenza vaccine in 2024 or 2025. Interview on 02/20/25 at 3:29 P.M. with the facility's Director of Nursing verified Resident #9 and Resident #17 were not educated or offered the influenza vaccine in 2024 or 2025. She reported all residents should be offered the vaccine on admission and yearly when they become available. Review of the Influenza and Pneumococcal Vaccine policy revised 04/06/21 revealed the purpose was to ensure all residents or their representative are educated in the benefits and side effects of receiving the influenza and Pneumococcal immunizations. The influenza vaccine will be offered between 10/01 and 03/31 each year. At admission the resident or their representative will receive education on the benefits and side effects of the immunizations including but not limited to the recommendations from the Centers for Disease Control (CDC). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365269 If continuation sheet Page 12 of 12