Inspection·February 27, 2023

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 family and staff interview, review of the medical record, review of the grievance log, review of the self reported incidents, and policy review, the facility failed to investigate allegations of misappropriation. This affected one resident (#01) out of one resident reviewed for misappropriation. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #01 revealed an admission date of 04/18/19 with diagnoses of cerebral palsy, chronic obstructive pulmonary disease, depression, and type II diabetes mellitus. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #01 had slightly impaired cognition and required extensive assistance of two people for bed mobility, dressing, toilet use, and hygiene, was totally dependent on two staff for transfers, and was totally dependent on one staff for eating. Review of a progress note dated 12/25/22 revealed Resident #01's family spoke with staff about missing items in Resident #01's room. Further review revealed family reported this was the third time an item had gone missing. The progress note revealed staff searched the room and was unable to locate the missing item. Review of the current care plan revealed no care area for personal items or the implementation of additional interventions. Review of the grievance log from October 2022 through February 2023 revealed no documentation of Resident #01 or her family reporting missing items. Interview on 02/21/23 at 4:00 P.M., with the Social Service Director (SSD) #605 revealed Resident #01's missing item was perfume. The SSD #605 further stated she had conversations with Resident #01's family and the facility offered to replace the item or reimburse the money. The SSD #605 stated the family was not interested in the facility replacing the item or reimbursing the money and therefore no grievance form or documentation of the incident was reported or investigated. Telephone interview on 02/21/23 at 4:08 P.M. with Resident #01's mother who reported she believed Resident #01's perfume was stolen at least four times. Further interview revealed Resident #01's mother only purchased perfume that cost at least $40.00 per bottle because Resident #01's skin was sensitive to less expensive perfumes. Resident #01's mother stated the facility offered to replace the perfume or reimburse her for the cost and she declined the offer. Interview on 02/23/23 at 4:04 P.M. with Licensed Practical Nurse (LPN) #307 verified on 12/25/22 Resident #01's family reported their concern of a new perfume bottle missing. LPN #307 stated she believed she reported the missing item to the Director of Nursing (DON). Interview on 02/27/23 at 2:52 P.M. with the DON revealed LPN #307 had not reported the missing perfume to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 2 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's self-reported incidents revealed no investigation into Resident #01's missing perfume in December 2022. Review of the facility policy Abuse and Neglect Protocol, revised 06/13/21, revealed misappropriation of resident property was included in the definition of abuse. Further review revealed all incidents of abuse should be investigated. Event ID: Facility ID: 365418 If continuation sheet Page 3 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident assessments were accurate. This affected three residents (#20, #57, and #61) out of 22 residents reviewed for accurate assessments. The facility census was 64. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #20 was admitted on [DATE]. Diagnoses included unspecified diastolic (congestive) heart failure, hypoxemia, malignant neoplasm of endometrium, acute respiratory failure with hypoxia, heart failure, hypertension, chronic pain, generalized anxiety disorder, hypothyroidism, benign neoplasm or uterine tubes and ligaments. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Section O of the assessment revealed hospice was not selected as a current special treatment, procedure, or program. Review of the physician order dated 11/02/22 revealed an order for hospice to follow resident care. Interview on 02/23/23 at approximately 9:00 A.M., with Administrator verified Resident #20 had been on hospice since admission. 2. Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant, acute respiratory failure with hypoxia, type one diabetes mellitus with ketoacidosis with coma, acute kidney failure, chronic kidney disease, rhabdomyolysis, rhabdomyolysis, encephalopathy, depression, type 1 diabetes mellitus with diabetic chronic kidney disease, osteoarthritis, hyperlipidemia, essential primary hypertension, chronic kidney disease stage three, gout, anxiety disorder. Review of the MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Section O of the assessment revealed dialysis was not selected as a current special treatment, procedure, or program. Review of the physician order dated 12/15/22 revealed a physician order for dialysis to be conducted every Monday, Wednesday, and Friday. Interview on 02/23/23 at 12:50 P.M., with the Director of Nursing (DON) verified Resident #57 received dialysis and was not accurately coded for dialysis on the MDS assessment. 3. Review of the medical record revealed Former Resident #61 was admitted on [DATE] and discharged on 01/23/23. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, hypertension, tracheostomy status, zygomatic fracture right side, fracture of right femur. Review of the MDS assessment dated [DATE] revealed the former resident was cognitively intact. Review of the discharge MDS assessment dated [DATE] revealed the resident's discharge was coded as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 4 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 0641 unplanned. Level of Harm - Minimal harm or potential for actual harm Review of the social service progress note dated 01/20/23 revealed social services discussed discharge planning and resident stated he planned to discharge on Monday 01/20/23 with the time to be determined. Discharge plans were reviewed with the resident. The resident would need a wheelchair, rolling walker, bedside commode and a home healthcare referral. Social services noted discharge arrangements would be made. Residents Affected - Few Interview on 02/22/23 at approximately 9:30 A.M., with Social Services Director #605 revealed Resident #61 was a planned discharge home and went as planned. Interview on 02/22/23 at 9:45 A.M., with MDS Coordinator Licensed Practical Nurse (LPN) #318 verified Resident #61's discharged was miscoded as unplanned when it was a planned discharged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 5 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans provided accurate activities of daily living (ADL) interventions. This affected four residents (#19, #39, #51, and #57) out of 16 resident care plans reviewed. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included cellulitis, COVID-19, paroxysmal atrial fibrillation, other forms of angina pectoris, visual hallucinations, chronic obstructive pulmonary disease, edema, chronic venous hypertension, anxiety disorder, major depressive disorder, hypertension, hyperlipidemia, and Barrett's esophagus with dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #19 was identified as requiring extensive two person assistance for bed mobility and transfers. Review of the care plan dated 01/21/23 revealed Resident #19 was care planned for having ADL self-care performance deficit due to disease process and required staff assistance to complete ADL tasks daily. Fluctuations are expected due to diagnosis and was at risk for decline in physical function. Interventions for the care plan identified bed mobility and transfers as requiring limited assistance with one person. Review of a note report dated 01/24/23 revealed per staff interview and documentation during the assessment reference date 01/18/23 to 01/24/23 extensive assist of two staff was proved for bed mobility, and transfer at least three times. Resident #19 was independent with set up assist for eating at least three times. Limited assist of one staff was provided for dressing, toilet use, and personal hygiene at least three times. 2. Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, anemia, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, ischemic cardiomyopathy, congestive heart failure, traumatic subdural hemorrhage, fracture of upper end of the ulna, subsequent encounter for closed fracture with routine healing. Review of the Minimum Data Set (MDS) assessment, dated 02/03/23, revealed the resident was cognitively intact. Resident #39 was identified as requiring extensive two person assistance for bed mobility and transfers, extensive one person assistance for dressing, toilet use, and personal hygiene, and total dependence for bathing. Review of the care plan, dated 01/30/23, revealed Resident #39 was care planned for having ADL self-care performance deficit due to disease process and required staff assistance to complete ADL tasks daily. Fluctuations are expected due to diagnosis and was at risk for decline in physical function. Interventions for the care plan identified the resident required limited assistance with one person for bed mobility, dressing, showering, personal hygiene, toileting and transfers. Review of note report dated 02/03/23 revealed per staff interview and documentation during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 6 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assessment reference date 01/28/23 to 02/03/23 extensive assist of two staff was provide for bed mobility and transfer at least three times. Extensive assist of one staff was provided for locomotion off unit, dressing, personal hygiene, and toile use at least three times. Resident was independent with setup for eating. Supervision with assist of one staff was provided for locomotion on unit at least three times. 3. Review of the medical record revealed Resident #51 was admitted on [DATE]. Diagnoses included Guillain-Barre Syndrome, muscle weakness, non-pressure chronic ulcer of other part of left foot, dependence on renal dialysis, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment, dated 01/06/23, revealed the resident was cognitively intact. Resident #51 was identified as requiring total dependence for transferring and bathing and extensive two person assistance for bed mobility, dressing, and personal hygiene. Review of the care plan dated 01/04/23 revealed Resident #51 was care planned for having ADL self-care performance deficit due to disease process and required staff assistance to complete ADL tasks daily. Fluctuations are expected due to diagnosis and was at risk for decline in physical function. Interventions for the care plan identified the resident required limited assistance with one person for hygiene/grooming and extensive one person assistance for bed mobility, dressing, showering, toileting, and transfers. Review of a note report dated 01/06/23 revealed per staff interview and documentation during the assessment reference date 12/30/22/ to 01/06/23 the resident was provided extensive assist of two staff for bed mobility, dressing, toilet use, and personal hygiene at least three times. Extensive assist of one staff was provided for locomotion and eating at least three times. Resident was totally dependent on two staff for transfer at least three times. 4. Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant, acute respiratory failure with hypoxia, type one diabetes mellitus with ketoacidosis with coma, acute kidney failure, chronic kidney disease, rhabdomyolysis, rhabdomyolysis, encephalopathy, depression, type I diabetes mellitus with diabetic chronic kidney disease, osteoarthritis, hyperlipidemia, essential primary hypertension, chronic kidney disease stage three, gout, anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/20/22, revealed the resident was severely cognitively impaired. Resident #57 was identified as requiring extensive one person assistance for eating, dressing, toilet use, and personal hygiene, extensive two personal assistance for bed mobility and transfers, and total dependence with two persons for bathing. Review of the care plan dated 12/20/22 revealed Resident #57 was care planned for having ADL self-care performance deficit due to disease process and required staff assistance to complete ADL tasks daily. Fluctuations are expected due to diagnosis and was at risk for decline in physical function. Interventions for the care plan identified the resident required set up and supervision with eating, limited assistance with one person for hygiene/grooming, extensive one person assistance for showering, and total dependence with two staff for transfers. Review of a note report dated 12/20/23 revealed per staff interview and documentation during the assessment reference date 12/13/22 to 12/20/22 the resident was provided extensive assist of two staff for bed mobility and transfer at least three times. Resident #57 was provided extensive assist of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 7 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm one staff for dressing, eating, toilet use, and personal hygiene at least three times. The resident relied totally on two assist from staff for locomotion on unit. Interview on 02/23/23 at 12:50 P.M., with the Director of Nursing (DON) verified ADL care plan interventions did not match the identified MDS functional status for Residents #19, #39, #51, and #57. Residents Affected - Some Review of facility policy titled Comprehensive Assessments, dated March 2022 verified comprehensive assessments are conducted to assist in developing person-centered care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 8 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of the medical record, and policy review, the facility failed to ensure a wound dressing was completed per physician orders. This affected one resident (#22) out of six residents reviewed for wound care. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 02/27/20 with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, chronic fatigue, and neuromuscular dysfunction of bladder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition and required extensive assistance of two people for bed mobility and dressing, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Review of the a physician order dated 02/15/23 revealed Resident #22 should receive silvadene cream to open red areas on abdomen, and cover with bordered gauze dressing twice daily, once on each shift. Observation and interview on 02/22/23 at 2:18 P.M. with Resident #22 revealed her abdominal bandage was dated 02/21/22. Resident #22 stated the staff normally changed the dressing twice daily. Observation on 02/23/23 at 10:18 A.M. revealed Resident #22's abdominal bandage was dated 02/21/22. Observation on 02/23/23 at 12:01 P.M. revealed Resident #22's abdominal bandage was dated 02/21/22. Concurrent interview with Registered Nurse (RN) #311 confirmed the bandage was dated 2/21/23 and stated the Wound Care Nurse, who rounded on 02/21/23, was presumably the last person to change the dressing. Interview with Resident #22 at that time revealed the staff used to change her wound dressing twice daily, and now they appeared to be skipping whole days. Review of the facility policy Medication and Treatment Orders, revised July 2016 revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state and treatments completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 9 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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, staff interview, review of the medical record, and review of the facility in-service, the facility failed to ensure staff reheated food to a safe temperature to prevent burns. This affected one resident (#16) out of one resident reviewed for hazards. The facility census was 64. Findings include: Review of the medical record for Resident #16 revealed an admission date of 01/15/19 with diagnoses of congestive heart failure, difficulty in walking, and unspecified dementia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance of two people for bed mobility, transfers, dressing and toileting, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Review of a physician order dated 12/16/22 revealed Resident #16 received a diet order of consistent carbohydrate and renal restrictions, mechanical soft textures, thin liquids, and chopped meats. Interview on 02/22/23 at 3:56 P.M. with the Director of Nursing (DON) revealed the facility completed an all-staff education on re-heating food in the microwave, including a directive to not exceed food temperatures of 165 degrees Fahrenheit (F). The DON stated thermometers and instructions were with each microwave on each resident floor. Observation on 02/22/23 at 4:02 P.M. of the second floor nutrition room revealed a microwave with a thermometer on it, and taped, highlighted instructions regarding goal reheating temperatures for microwaved foods. Observation with the Administrator on 02/22/23 at 4:08 P.M. in the nutrition room on the second floor, revealed State Tested Nurse Aide (STNA) #801 reheating leftovers for Resident #16 in the microwave. The STNA #801 reheated the food in a leftover styrofoam container for one minute and 40 seconds, stopping twice to remove the item from the microwave and stir the food. At no time did the STNA #801 use the thermometer to check the temperature of the food. Before the STNA #801 left the nutrition room, the Administrator asked the STNA #801 how she knew how hot the food was. The STNA #801 opened the styrofoam container and held her hand above the food and indicated it was not too hot. The STNA #801 then exited the nutrition room and took the microwaved food to Resident #16's room. Interview at that time with the Administrator confirmed the STNA #801 did not use a thermometer to monitor the temperature of the reheated food item. Further subsequent observation on 02/22/23 at approximately 4:10 P.M. revealed the Administrator instructing the STNA #801 to return to the nutrition room and use the thermometer to check the temperature of the food. The STNA #801 returned to the nutrition room, used the thermometer to check the temperature of the food, then took the food to Resident #16. Interview on 02/22/23 at 4:31 P.M. with the STNA #801 stated the temperature of the reheated food for Resident #16 was 155 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 10 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 Review of the in-service provided 01/20/23 through 01/22/23 revealed staff were educated on the Food Reheating Policy. Review of the undated policy titled Food Safety Requirements revealed microwaved foods should reach a temperature of 165 degrees F. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 11 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 observation, medical record review, staff interview, and facility urinary catheter care policy, the facility failed to ensure appropriate technique was implemented to prevent cross contamination. This affected one resident (#22) out of three residents identified with an indwelling urinary catheter. The facility census 64. Findings include: Resident #22 admitted to the facility on [DATE] with diagnosis including acute respiratory failure with hypoxia, anxiety disorder, chronic fatigue, neuromuscular dysfunction of bladder and other specified abnormal findings of blood chemistry. According to the minimum data set assessment (MDS) dated [DATE] assessed Resident #22 with intact cognition and required extensive assistance of two people for bed mobility and dressing, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Further review revealed Resident #22 had an indwelling catheter. On 04/20/20 the physician ordered indwelling urinary catheter (Foley catheter) care to be completed every shift. Review of the Foley catheter care plan implemented on 02/28/20 and revised on 05/14/22 noted interventions to include the following; resident will be/remain free from catheter-related trauma through review date. Resident will show no signs or symptoms of urinary infection through review date. Change catheter per policy. Complete catheter care per policy. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to physician for signs or symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever. Observation on 02/23/23 at 10:18 A.M. noted State Tested Nurse Aide (STNA) #223 to obtain a warm basin of water and placed it at the bedside. STNA #223 proceeded to pour a small amount of the residents personal cleansing cream (Tena Cleansing Cream) into the basin. STNA #223 placed disposable gloves on and wet a washcloth inside the basin proceeding to cleanse the side of the residents perineum followed by the center changing areas of the washcloth with each swipe. No attempts to rinse the perineum were attempted and STNA #223 utilized a towel to dry the residents perineal region. STNA #223 obtained a second clean washcloth wet the washcloth in the same basin. Using the washcloth STNA #223 cleansed up and down the tubing from insertion site with wipes reintroducing potentially soiled contaminants to the insertion site. No attempt to thoroughly cleanse the insertion site with soapy water was attempted. No rinsing with a second washcloth was attempted and the tubing was dried with the same technique, cross contaminating the tubing multiple swipes. Interview with STNA #223 immediately following the procedure on 02/23/23 confirmed no approved cleanser was utilized, a sufficient amount of cleanser was not placed to the washcloths, no attempts to rinse the residents perineum or catheter tubing was attempted and cross contamination occurred when cleansing and drying the catheter tubing. Review of the facility policy titled Catheter Care, Urinary, revised September 2014, revealed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 12 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 nondominant hand separate labia of the female resident. Maintain the position of this hand throughout the procedure. Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the wash cloth and cleanse around the urethral meatus. Do not allow the wash cloth to drag on the residents skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. On 02/23/23 at 1:45 A.M. interview with the Director of Nursing verified facility catheter care policy indicates soap was to be used when cleansing the residents perineum and tubing. In addition, no attempts to rinse with clean water and cross contamination occurred during catheter care to Resident #22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 13 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation of the daily staff posting, staff interview, and review of the Facility Assessment, the facility failed to ensure the staff posting included the actual hours worked by nurses and aides in the facility. This had the potential to affect all residents in the facility. The facility census was 64. Residents Affected - Many Findings include: Observation of the daily staff posting from 01/22/23 through 02/21/23 revealed the document included the date, the daily census, and the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State Tested Nurse Aides (STNA). The staff posting did not include the actual total hours worked by the RNs, the LPNs or the STNAs. Review of the Facility Assessment, updated 02/21/23 revealed the facility required nurses to work 60 to 75 hours per day and STNAs to work 98 to 130 hours per day. Interview on 02/23/23 at 11:02 A.M. with the Medical Records #01 revealed the staff posting included only the number of staff scheduled that day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 14 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of the facility's temperature logs, and review of the facility's posted guidance, the facility failed to ensure food items reached the appropriate internal temperature before serving the items to residents. This affected 12 residents (#04, #14, #15, #16, #17, #18, #34, #36, #42, #54, #57, and #214) out of 64 residents receiving meals in the facility. The facility census was 64. Findings include: Observation on 02/22/23 at 11:20 A.M. revealed the Dietary [NAME] (DC) #402 taking temperatures of all food items on the tray line in preparation for meal service. The temperature of mechanical soft Salisbury steak was 150 degrees Fahrenheit (F) and the temperature of the reheated, leftover lasagna was 148 degrees F. Interview on 02/22/23 at approximately 11:25 A.M. with the Dietary Manager (DM) #01 revealed the mechanical soft meat should be at least 155 degrees F. The DC #402 acknowledged the information but did not reheat the mechanical soft Salisbury steak. Interview on 02/22/23 at approximately 11:27 A.M. with the DC #402 confirmed the lasagna was cooked the previous day and was reheated on 02/22/23 as a menu alternative. Observations during tray line on 02/22/23 between approximately 11:30 A.M. and approximately 12:30 P.M. revealed seven residents (#214, #54, #18, #16, #17, #15, and #36) received the mechanical soft Salisbury steak. Interviews on 02/22/23 at approximately 12:17 P.M. and 12:30 P.M. with the DC #402 revealed two residents (#4 and #42) received the lasagna. Continued interview at approximately 12:30 P.M. with the DC #402 confirmed she did not reheat the mechanical soft Salisbury steak after determining it did not meet the minimum internal temperature of 155 degrees F before serving it to residents. Interview on 02/22/23 at approximately 12:35 P.M. with the DM #01 confirmed the facility's guidance for cooked ground meats required a minimum internal temperature of 155 degrees F, and reheated, previously cooked and cooled food items, required a minimum internal temperature of 165 degrees F. Interview on 02/23/23 at 1:35 P.M. with the DM #01 and the DC #402 confirmed no temperature was taken of the Salisbury steak before it was ground into mechanical soft texture. The DC #402 stated she only took temperatures once food was in the steamtable on the tray line and did not take the temperature of food items upon completion of cooking. Review of the facility-provided list of residents on a mechanical soft diet included Resident #14, Resident #34, and Resident #57 in addition to the seven residents noted previously (#214, #54, #18, #16, #17, #15, and #36). Review of the food temperatures for the noon meal on 02/22/23 confirmed the documented temperature of the mechanical soft Salisbury steak was 150 degrees F, and the temperature of the spinach lasagna was 148 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 15 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 Review of the Food Safety guidance posted in the kitchen revealed cooked ground meats should be cooked to an internal temperature of 155 degrees F. The guidance further revealed food items previously cooked, then cooled should be reheated to a minimum internal temperature of 165 degrees F. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 16 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to provide accurate documentation of wound care completed in the medical record. This affect resident two residents (#19 and #22) out of six residents reviewed for wound care. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included cellulitis, COVID-19, paroxysmal atrial fibrillation, other forms of angina pectoris, visual hallucinations, chronic obstructive pulmonary disease, edema, hypertension, anxiety disorder, major depressive disorder, hyperlipidemia, and Barrett's esophagus with dysphasia. Review of the Minimum Data Set (MDS) assessment, dated 01/24/23, revealed the resident was cognitively intact. Resident #19 required limited assistance with toilet use, personal hygiene and dressing and extensive assistance with bed mobility and transfers. Resident #19 was frequently incontinent of bowel and bladder and had a stage four pressure ulcer. Review of physician order, dated 01/18/23 and updated 01/25/23, revealed to cleanse coccyx wound with one quarter strength dakins apply one quarter strength dakins moisten gauze and cover with border foam twice a day and as needed. Review of the Treatment Administrative Record (TAR), dated 02/21/23, revealed the treatment for the coccyx wound from 7:00 A.M., to 7:00 P.M. was completed with a code of nine indicating to see progress notes. The treatment scheduled for 7:00 P.M. to 7:00 A.M. was checked off as completed by Licensed Practical Nurse #704. Review of the wound care progress note, completed 02/21/23 at 3:41 P.M., revealed Resident #19 had a stage four pressure ulcer which the resident reports is more than seven years old (not facility acquired) and has an improved status. The current measurements were 2.04 centimeters (cm) by 0.7 (cm) by 0.4 (cm). Physician orders include to pack with dakins moistened gauze, cover with dry water resistant dressing, may cleanse with normal saline or wound cleanser and pack with calcium alginate if no dakins available and may use house available dakins. Ensure compliance with turning protocol, wheelchair cushion, and specialty bed. Observation on 02/22/23 at 3:05 P.M. with Registered Nurse (RN) #311 and LPN #310 revealed Resident #19's wound dressing change. The observation revealed the prior dressing was dated 02/21/23. Interview on 02/23/23 at 11:30 a.m. with the Director of Nursing (DON) verified the wound treatment was checked off as complete by LPN #704 when in fact it was not completed on that shift. The DON stated LPN #704 had reported she came in early at 3:00 P.M. for the 7:00 P.M. to 7:00 A.M. shift and was told the wound care was already completed by wound care for the day therefore marked it completed by herself for the 7:00 P.M. to 7:00 A.M. shift. 2. Review of the medical record for Resident #22 revealed an admission date of 02/27/20 with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, chronic fatigue, neuromuscular dysfunction of bladder (added 6/3/20). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 17 of 18 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed Resident #22 had intact cognition and required extensive assistance of two people for bed mobility and dressing, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Review of a physician order dated 02/15/23 revealed Resident #22 should receive silvadene cream to open red areas on abdomen, and cover with bordered gauze dressing twice daily, once on each shift. Review of the February 2023 treatment administration record (TAR) revealed Resident #22 received a dressing change on the second shift of 02/22/23. Interview on 02/22/23 at 2:18 P.M. with Resident #22 revealed the staff normally changed the dressing twice daily. Observation on 02/23/23 at 10:18 A.M. revealed Resident #22's abdominal bandage was dated 02/21/22. Observation on 02/23/23 at 12:01 P.M. revealed Resident #22's abdominal bandage was dated 02/21/22. Concurrent interview with Registered Nurse (RN) #311 confirmed the bandage was dated 2/21/23 and stated the Wound Care Nurse, who rounded on 02/21/23, was presumably the last person to change the dressing. Interview with Resident #22 at that time revealed the staff used to change her wound dressing twice daily, and now they appeared to be skipping whole days. Interview on 02/23/23 at 3:17 P.M. with the Regional Clinical Director #800 confirmed the February 2023 TAR for Resident #22 revealed an order for the wound dressing to be completed twice daily, and the TAR indicated the wound dressing was completed on 02/22/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 18 of 18