Inspection·December 18, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 12/11/23 at 8:50 A.M. with Resident #09, the resident reported he had not received a shower on 12/04/23. The resident reported STNA #195 was trying to help out by giving him a shower later on in the night. Resident #09 reported it was not unusual to receive a shower late at night. This deficiency represents an incidental finding discovered during investigation under Complaint Number OH00148949. Event ID: Facility ID: 365418 If continuation sheet Page 2 of 14 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 12/18/2023 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 - Immediate jeopardy to resident health or safety 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, resident and staff interview, interview with Wound Care Nurse Practitioner (NP) #700, review of hospital records, review of an incident report, review of a facility self-reported incident (SRI), review of the facility investigation, review of witness statements, and review of a policy, the facility failed to ensure a resident (#09) was free from avoidable burns inflicted by a staff member. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death when on 12/05/23 at approximately 2:45 A.M., State Tested Nurse Aide (STNA) #195 used her personal lighter in an attempt to remove a diabetic wound dressing from Resident #09's right foot. Subsequently, Resident #09's wound dressing was set on fire, causing the resident and STNA #195 to catch fire, and Resident #09 was later hospitalized and treated for first-degree (top layer of skin) and second-degree (first two layer of skin) burns. This affected one (#09) of one resident reviewed for accidents. The facility census was 65. On 12/07/23 at 4:34 P.M., the Administrator and Regional Director of Operations #907 were notified Immediate Jeopardy began on 12/05/23 at approximately 2:45 A.M., when STNA #195 used her personal lighter in an attempt to remove a dressing on Resident #09's foot. STNA #195 took Resident #09 to the shower room for bathing where a diabetic wound dressing to Resident #09's right foot became wet and needed changed. STNA #195 attempted to independently remove the dressing but could not locate scissors to cut the dressing, so the nurse aide utilized a personal lighter to the wound dressing in an attempt to remove it from Resident #09's right foot. The flame from STNA #195's lighter ignited the wound dressing on Resident #09's right foot as well as STNA #195's left pant leg. Both fires to Resident #09 and STNA #195 were extinguished with staff intervention, and Resident #09 was sent to the hospitalized and treated for first and second-degree burns. The Immediate Jeopardy was removed on 12/06/23 when the facility implemented the following corrective actions: • On 12/05/23 at 2:45 A.M., STNA #201 entered the shower room and extinguished the fire to Resident #09's right foot dressing. • On 12/05/23 at 2:46 A.M., Agency Registered Nurse (RN) #488 was notified of the incident and assessed Resident #09. • On 12/05/23 at 2:50 A.M., Agency RN #488 notified the Director of Nursing (DON) of the incident. STNA #195 was interviewed and was immediately suspended pending investigation. STNA #195 had not worked since the suspension was initiated. • On 12/05/23 at 3:00 A.M., Agency RN #488 notified the on-call provider of the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 3 of 14 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 12/18/2023 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 - Immediate jeopardy to resident health or safety On 12/05/23 at 3:10 A.M., a treatment was ordered for Resident #09 for a burn wound caused by the fire and applied by Agency RN #488. • Residents Affected - Few On 12/05/23 at 4:05 A.M., Agency RN #488 completed a pain assessment on Resident #09. • On 12/05/23 at 4:30 A.M., Agency RN #488 administered as-needed pain medication (acetaminophen) to Resident #09. • On 12/05/23 at 5:30 A.M., the DON assessed Resident #09. • On 12/05/23 at 9:30 A.M., Wound Care Nurse Practitioner (NP) #700 assessed Resident #09 with an increased area of concern noted to the burn wound. • On 12/05/23 at 10:00 A.M., the DON spoke with Resident #09 to discuss the occurrence and injury with family and the resident agreed. • On 12/05/23 at 10:15 A.M., Resident #09's family was notified of the incident. • On 12/05/23 at 10:30 A.M., Physician #704 was notified and new orders to administer a dose of oxycodone (narcotic pain medication) to Resident #09 and to send Resident #09 to the emergency department (ED) for evaluation and treatment were received by the DON. • On 12/05/23 at 10:37 A.M., new orders were received for additional routine and as-needed pain medication for Resident #09. • On 12/05/23 at 11:10 A.M., the Administrator submitted an SRI to the State Survey Agency to report the incident. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 4 of 14 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 12/18/2023 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 On 12/05/23 at 11:15 A.M., RN #489 administered pain medication to Resident #09 per the new physician order. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On 12/05/23 by 7:00 P.M., the Administrator, the DON, Director of Clinical Services #500, Director of Operations #505, Regional Nurse #510, and the Regional Director of Operations #907 reviewed and updated the STNA orientation checklist. • On 12/05/23 by 7:00 P.M., the Assistant Director of Nursing (ADON) performed skin assessments on all residents assigned to STNA #195. • On 12/05/23 by 7:00 P.M., the ADON and Unit Manager #912 assessed all residents with a dressing in place to ensure treatments were in place and no other injuries were noted. • On 12/05/23 by 7:00 P.M., the Administrator, the DON, and Regional Nurse #510 completed the interdisciplinary team investigation. • On 12/05/23 by 10:00 P.M., the DON/designee educated all staff that licensed nurses were the only individuals permitted to remove dressings, and also provided education on scope of practice, standards of practice, and reporting incidents. • On 12/05/23 by 10:00 P.M., the Administrator/designee educated all staff on the policy for abuse and neglect, and the facility's fire policy including use of lighters. • Beginning 12/06/23, the DON/designee would conduct audits related to dressings and protocol for removing dressings four times weekly for two weeks, followed by two times weekly for two months, and then as determined by the Quality Assurance Performance Improvement (QAPI) committee. • Beginning 12/06/23, the Administrator/designee would conduct random audits to ensure fire safety practices were being followed and that staff understood the fire safety policies three times weekly for four weeks, followed by two times weekly for two months, and then as determined by the QAPI committee. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 5 of 14 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 12/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Interviews on 12/11/23 between 11:49 A.M. and 2:10 P.M. with RN #489, STNA #347, STNA #900, and STNA #350, all verified education was provided by the Administrator/designee and DON/designee for all staff, and all possessed adequate knowledge of the education content. Although the Immediate Jeopardy was removed on 12/06/23, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that was not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan to ensure all residents at risk for staff removing wound dressings in an unsafe manner were monitored appropriately for on-going compliance. Findings include: Review of the medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with a foot ulcer, cellulitis, heart disease, dysphagia, arthritis, pain in left foot, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/23, revealed the resident was assessed as cognitively intact. The resident was dependent on staff assistance for toileting, bathing, dressing, and putting on and removing footwear. The resident was assessed with a diabetic foot ulcer with applications of ointments and medications and dressings to the feet. Review of the plan of care, revised 10/09/23, revealed Resident #09 had an actual impairment to skin integrity of the right heel to include a diabetic foot ulcer. The resident was followed by a wound team. Interventions included following facility protocols for treatment of the injury, monitoring the dressing to ensure it was intact and adhering, and providing treatment as ordered. Review of Resident #09's physician orders for November 2023 revealed an order to cleanse the right heel with Dakins solution, apply Dakins-moistened fluffed gauze, cover with ABD (absorbent pad), and wrap with rolled gauze. Instructions for the dressing included to date and time the dressing and change every day, and as needed, if the dressing was soiled, loose, or dislodged. Review of the incident report dated 12/05/23 and timed 2:45 A.M., revealed Resident #09 had a shower. After the shower, STNA #195 wanted to remove the dressing to the resident's right foot and did not have scissors. STNA #195 used her lighter to start to unravel the dressing; however, Resident #09's foot dressing caught fire and a second STNA extinguished the fire. Review of the nursing progress notes dated 12/05/23 and timed 3:00 A.M. revealed the DON received a call from Agency RN #488 indicating Resident #09 had altered skin integrity to his right foot. The nurse was advised to call the certified nurse practitioner (CNP) with her assessment. An order was received for a dressing to be applied to Resident #09's right foot. Review of the skin assessment dated [DATE] and timed 5:32 A.M., revealed Resident #09 had a burn to the top of right foot, which was four (4.0) centimeters (cm) long by eight (8.0) cm wide, a burn to the medial aspect of the right foot which was 10.0 cm long by 8.0 cm wide, and a blister to medial aspect of the right foot which was 5.5 cm long by 6.5 cm wide. Review of the nursing progress notes dated 12/05/23 and timed 5:36 A.M., revealed the DON assessed Resident #09's right foot and noted two areas to the top of the foot with the top layer of skin removed and a pink wound bed were present. There was an area to the medial right foot extending to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 6 of 14 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 12/18/2023 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 - Immediate jeopardy to resident health or safety heel with the top layer of skin removed and pink wound bed also noted. There was also an intact blister to the lateral right heel and flesh-tone was noted. Review of the nursing progress notes dated 12/05/23 and timed 9:30 A.M. revealed the Wound Care NP #700 assessed Resident #09's wounds and changes were noted from an earlier assessment. The facility received new orders for care and treatment of Resident #09 at that time. Residents Affected - Few Review of the wound care practitioner notes dated 12/05/23 and timed 10:42 A.M., revealed Resident #09 was seen for a right heal diabetic ulcer, a new skin tear to left hand from recent fall, and new skin breakdown to right foot reported per nursing staff. Per Resident #09's report, the resident's right wound dressing caught fire early that morning causing a burn to the right foot. The exact cause for this was being investigated per facility staff. A dressing was applied to the resident's right foot early that morning and found to be saturated at the time of assessment due to heavy drainage. The wound was noted as a right foot burn with treatment recommendations to cleanse with normal saline, apply Silvadene one percent (1%) cream followed by oil emulsion dressing to the base of the wound, secure with ABD and rolled gauze, and change twice per day and as needed. Review of the wound assessment report dated 12/05/23, revealed Resident #09 was seen for the diabetic foot ulcer, a new skin tear to the left hand, and new burns to the right foot. The burns were 16.0 cm long by 24.5 wide by 0.2 cm deep. Review of the health status notes dated 12/05/23 and timed 11:16 A.M., revealed the physician was called with a description of Resident #09's wounds. An order for pain medication and to send the resident to the ED was received. Review of the health status notes dated 12/05/23 and timed 11:36 A.M., revealed oxycodone was administered to Resident #09. The ED was notified of the resident's pending arrival, and was sent to the ED. The resident's family was contacted and updated. Review of the hospital records revealed Resident #09 was seen and admitted on [DATE] at 12:33 P.M. with a burn wound to the right foot. A nurse aide was trying to burn the dressing to remove it, and the dressing caught fire causing a burn to the dorsum (top) and plantar (bottom) aspects of the right foot. The resident had circumferential ulceration from the dorsum of the foot extending along the plantar vault and lateral aspects of the right foot and ankle from the burn wound. Review of radiographs of the right foot revealed osteomyelitis (bone infection) of the right calcaneus (heel bone) and the burn wound appeared to be mostly superficial without any exposure of deep structures. Selective debridement was performed on the burn wound to remove nonviable and sloughing (yellow, tan, gray green tissue that is usually moist and adhered to the wound bed) skin with a suture removal kit. The procedure was performed at the bedside down to the layer of the dermis (connective tissue layer) near the area of the burn wounds. The resident was prescribed vancomycin (antibiotic) 1,000 milligrams in sodium chloride intravenously every 24 hours and continued use of Silvadene to the burn wounds. Review of the hospitalist notes dated 12/06/23 revealed the burn was a first to second-degree burn. Review of the facility SRI dated 12/05/23 at 11:10 A.M., revealed the facility initiated a report of an incident involving a dressing to Resident #09's foot with an injury noted, and the resident was sent to the ED. Review of the facility investigative timeline, revealed Resident #09 received a shower on 12/05/23 between 2:30 A.M. and 2:45 A.M. At 2:45 A.M., the resident's wound dressing was lit on fire by STNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 7 of 14 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 12/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few #195, and STNA #195 attempted to extinguish the fire and called for help. STNA #201 then entered the shower room and extinguished the fire. The nurse on duty was notified of the incident at 2:46 A.M. and assessed Resident #09 at 2:50 A.M. and notified the DON. The on-call provider was notified of the incident at 3:00 A.M. and new orders were received. The DON notified the Administrator at 3:10 A.M. and Agency RN #488 followed new wound care orders. At 3:30 A.M., the DON instructed STNA #195 to write a statement and leave the building. STNA #195 left the building at 4:00 A.M. At this time, Resident #09 was in his wheelchair, located in his room, and with no distress. The resident received acetaminophen at 4:05 A.M. The DON assessed the foot wound at 5:30 A.M. A wound care CNP assessed the wound at 9:30 A.M. and determined it had worsened. A new order for oxycodone was received at 10:37 A.M. The administrator submitted the SRI at 11:10 A.M. The physician was notified of the wound status and gave an order for pain medication and transfer to emergency department at 11:15 A.M. The DON called report to the emergency department and notified the resident's family at 11:30 A.M. Review of the written statement provided by STNA #195, dated 12/05/23, revealed STNA #195 assisted Resident #09 with his shower. Once finished, STNA #195 noticed the resident's bandages needed changed so she notified the nurse. The nurse asked STNA #195 to let her know once the resident was in bed so the nurse could perform wound care. STNA #195 finished caring for the resident and removed the bandage that was wet and peeling. STNA #195 started to finish removing what was already coming off. The tape had gotten stuck to the bandage and kept pulling. STNA #195 could not find any scissors, so she tried to burn the fringe to remove it. It immediately caught fire and the fire kept building like a forest fire. STNA #195 called the coworker who was closest to her (STNA #201), the staff members put out the fire, and notified the nurse immediately after. Review of the written statement provided by STNA #201, dated 12/05/23, revealed STNA #195 called STNA #201 into the shower room as STNA #201 was going to chart. STNA #201 saw that Resident #09's foot was on fire. STNA #201 took a towel and put the fire out. STNA #201 asked the resident if he was okay or if anything was burning or hurting. STNA #201 then asked STNA #195 if she was okay. After making sure everything was okay, STNA #201 went and retrieved the nurse. Review of the written statement provided by Agency RN #488, dated 12/05/23, revealed an STNA gave Resident #09 a shower at approximately 2:30 A.M. Agency RN #488 informed the STNA that Agency RN #488 would change the resident's dressing once he was in bed. At approximately 2:45 A.M., an STNA came and told the nurse Resident #09 had been injured from a burn to the right foot. Upon assessment of the right foot, the color was pink and top of the foot's epidermis (top layer of skin) was impaired. The resident denied pain and had full range of motion. First aide was given, and the foot was wrapped and dressed with Kerlix and ABD. The STNA indicated she was removing a bandage, and the threads began to pull. The STNA used a lighter to burn away threads and burned Resident #09's foot. During an interview on 12/07/23 at 12:59 P.M. with the Administrator, the Administrator reported early on the morning of 12/05/23, STNA #195 gave Resident #09 a shower. The resident's dressing was wet following the shower. The STNA informed the nurse the dressing needed to be changed, and the nurse stated she would change it soon. The STNA took it upon herself to take the dressing off. There was tape that was caught on the edges of the dressing, and the STNA did not have a pair of scissors, so she pulled a lighter out of her pocket and attempted to burn the edges of the dressing. The Administrator stated STNA #195 stated the entire thing lit up like a forest fire. The Administrator reported there were absolutely no open flames allowed in the building, so staff should never have lit a lighter. During an interview on 12/07/23 at 1:58 P.M. with STNA #195, the staff member reported assisting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 8 of 14 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 12/18/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #09 with a shower on the early morning of 12/05/23. Following the shower, the resident's bandages were almost all the way off due to the shower. STNA #195 notified the nurse on duty that the dressing needed to be changed. The nurse was busy at the time, so STNA #195 decided to remove the dressing. STNA #195 reported she began unraveling the dressing and it became stuck. STNA #195 could not find a pair of scissors, so she used her personal lighter to attempt to burn the fringe off around the bandage. Resident #09's dressing and STNA #195's entire left leg immediately caught fire. STNA #195 began to panic and rolled on the ground while yelling for help. STNA #201 entered the shower room and got both fires out using wet towels. Both STNAs then ran out of the shower room and informed the nurse of what had happened. The nurse immediately assessed the resident. STNA #195 reported she had not realized removing a dressing was considered wound care and realized she should not have used a lighter. During an interview on 12/07/23 at 7:12 P.M. with STNA #201, the staff member reported on 12/05/23 at approximately 2:45 A.M., she heard STNA #195 screaming her name from the shower room. STNA #201 ran into the shower room and saw that Resident #09's foot was on fire. STNA #201 grabbed a towel and smothered the fire. STNA #201 reported the bottom of a shower curtain was also on fire, so she yanked it down and the fire went out as the curtain fell into a bathtub. STNA #201 did not recall whether STNA #195 was also on fire. STNA #201 reported that STNA #195 stated she used a lighter in an attempt to remove Resident #09's dressing and it exploded into a fire. STNA #201 reported seeing the lighter and that it was a regular, standard lighter. During an interview on 12/07/23 at 7:31 P.M. with the DON, the DON reported assessing Resident #09's foot on the early morning of 12/05/23. The DON reported the areas on the resident's foot appeared pink with surface skin missing. When Wound Care NP #700 assessed the resident several hours later, the skin on the edges of the burns was peeling and the DON and Wound Care NP #700 were concerned since the wound was a burn it may have been worsening. The resident was subsequently sent to the ED for evaluation. Interview on 12/11/23 at 8:50 A.M. with Resident #09, revealed the resident recently returned from the hospital following an incident at the facility. Resident #09 reported a nurse aide assisted him with a shower and could not get his dressing off, so she used her lighter. Resident #09 reported his whole dressing caught on fire and the nurse aide's uniform caught on fire twice. During an interview on 12/11/23 at 2:06 P.M. with Wound Care NP #700, the NP reported she had previously been seeing Resident #09 for a diabetic foot ulcer. On 12/05/23, Wound Care NP #700 assessed Resident #09's foot for burns. Wound Care NP #700 and the DON discussed their assessments from that day and determined that the wound had worsened between assessments. Wound Care NP #700 reported this was due to the burns looking more reddish or pinkish during the DON's assessment, and when Wound Care NP #700 assessed the burn was starting to blister and draining heavily. Wound Care NP #700 reported originally documenting the burn as a third degree burn because it appeared full thickness. Upon review of hospital podiatry notes, the hospital only had to debride down to the dermis which was indicative of a second-degree burn. Review of a facility policy titled, Wound Care, revised October 2010, revealed the purpose of the procedure is to provide guidelines for the care of wounds by licensed nursing staff to promote healing. There was no mention of the use of a lighter to remove a wound dressing in the procedure. This deficiency represents non-compliance investigated under Complaint Master Number OH00148949. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 9 of 14 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 12/18/2023 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, review of the witness statements, review of nursing staff schedules, review of local law enforcement records, resident interview, staff interview, review of a facility policy, and review of facility corrective action, the facility failed to ensure a resident received assistance with incontinence care in a timely manner. This affected one (#05) of three residents reviewed for incontinence care. The facility census was 65. Findings include: Review of Resident #05's medical record revealed the resident was originally admitted to the facility on [DATE]. Diagnoses included permanent atrial fibrillation, hypertension, epilepsy, vertigo, heart failure, muscle weakness, anxiety, and end stage renal disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/03/23, revealed Resident #05 was cognitively intact. The resident was always incontinent of urine and occasionally incontinent of bowel. The resident was dependent on staff assistance for toileting and dressing. Review of the plan of care, revised 10/19/23, revealed Resident #05 had episodes of bowel incontinence. Interventions included checking resident every two hours and assisting with toileting as needed, and providing perineal care after each incontinent episode. Review of the incident report dated 11/19/23, revealed Resident #05 asked to be changed at approximately 6:30 P.M. on 11/18/23. A state tested nurse aide (STNA) told the resident she was finishing up another resident. When she returned at 6:40 P.M., the resident told the STNA she would have to wait just like he did. Shift change then occurred. There was one STNA on the floor. The resident asked to be changed a few times and the STNA asked him to hold on. The STNA later changed the resident. Once she left the room, the daughter was on the unit and the police arrived thereafter. Review of the facility SRI dated 11/19/23 and timed 7:53 A.M., revealed Resident #05 reported his incontinence brief had not been changed in over 10 hours. The resident called his daughter to complain, and his daughter called the local police to allege elder abuse. Review of the SRI narrative summary of incident and investigation, revealed on 11/19/23 at approximately 12:17 A.M., Resident #05's son-in-law called the local police department to allege the resident was a victim of elder abuse. The Administrator and Director of Nursing (DON) were notified of the allegation when the police arrived at the facility. The investigation revealed Resident #05 was changed at approximately 3:30 P.M. on 11/18/23. Staff offered to change the resident again around 6:45 P.M., and the resident refused at that time. The resident then asked an STNA to change him sometime after her shift started at 7:00 P.M. The STNA asked Resident #05 to wait until a second nurse aide arrived on shift. The STNA then became busy performing care for other residents and lost track of time. The STNA stated she remembered around midnight and approached Resident #05 to change him. She assisted him and then by the time she was leaving the room, the resident's daughter and son-in-law had arrived at the facility. Staffing was reviewed for the day in question and was in compliance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 10 of 14 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 12/18/2023 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 state minimums. Level of Harm - Minimal harm or potential for actual harm Review of the local law enforcement records dated 11/19/23, revealed an officer responded to the facility regarding a complaint of elderly abuse. The person who called the police reported Resident #05 was being neglected and that his incontinence briefs had not been changed in over nine (9) hours. The officer spoke with Resident #05 who stated he was doing okay, but was frustrated with the lack of care provided. Residents Affected - Few Review of the written statement provided by Resident #05, dated 11/19/23, revealed the resident started asking to be changed at approximately 3:00 P.M. on 11/18/23. The nurse aide who answered gave an excuse, left, and did not return. The resident put his call light on and asked three or four times and did not get changed. At 6:30 P.M., the nurse aide offered to change him, but he was watering his plants, so he asked her to come back. A nurse aide finally came to get him cleaned up, possibly around 10:50 P.M. or 11:50 P.M. on 11/18/23. The resident called his daughter at approximately 11:00 P.M. Review of the written statement provided by STNA #533, dated 11/20/23, revealed Resident #05 allowed staff to change him around 3:00 P.M. or 3:30 P.M. on 11/18/23. Sometime after supper, the resident asked to be changed. Staff were on their way to change someone else so asked Resident #05 to wait a minute. When staff returned, Resident #05 was watering his plants and stated since staff made him wait, the staff could now wait. Review of the written statement provided by STNA #900, dated 11/19/23, revealed Resident #05 stated he needed to be changed at approximately 6:30 P.M. on 11/18/23. STNA #900 informed the resident she was in the middle of providing care for another resident and would come to his room after. After finishing with the other resident, STNA #900 approached Resident #05 and asked if he was ready to be changed. The resident indicated because he had to wait, the staff could wait too. STNA #900 communicated the conversation with the oncoming shift during report. Review of the written statement provided by STNA #195, dated 11/19/23, revealed the staff member began her shift at 7:00 P.M. on 11/18/23. Shortly after, Resident #05 asked her to change him. STNA #195 asked the resident to wait until the second nurse aide came in. STNA #195 got busy doing other things and lost track of time. STNA #195 got to Resident #05 as soon as she remembered. When STNA #195 finished changing Resident #05, she walked out of the room and Resident #05's daughter was coming out of the elevator. When STNA #195 changed Resident #05, his incontinence brief was not saturated. Review of the undated timeline provided by Registered Nurse (RN) #423 revealed Resident #05's family arrived at the facility at approximately 12:00 A.M. on 11/19/23. Between approximately 12:30 A.M. and 1:00 A.M., the police arrived and stated they received a report of elder abuse. The police and family talked in the hallway regarding Resident #05 not being changed since 3:00 P.M. on 11/18/23. Resident #05's daughter wanted to speak with the Administrator. RN #423 called the DON, who spoke with the daughter. The family left around 1:00 A.M. and said they would be waiting for the Administrator's call. Review of the nursing staff schedules for 11/18/23 through 11/19/23, revealed there was one STNA working on the second floor from 7:00 P.M. to 7:00 A.M. Interview on 12/07/23 at 12:59 P.M. with the Administrator reported receiving a call in the early morning on 11/19/23 that the police were at the facility and Resident #05's family alleged Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 11 of 14 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 12/18/2023 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 #05 had not been changed in possibly 11 hours. The Administrator reported it had not been 11 hours and the resident had refused to be changed when offered on one occasion. The Administrator reported Resident #05 was provided with incontinence care at approximately 3:15 P.M. on 11/18/23. The resident asked to be changed again at approximately 6:30 P.M. and the STNA was in the middle of caring for another resident. When the STNA returned at approximately 6:45 P.M. and offered to change Resident #05, the resident stated he because the nurse aide made him wait, the nurse aide would have to wait too, and was not changed. When the STNA who responded at 6:45 P.M.'s shift ended at 7:00 P.M., Resident #05 then asked the oncoming STNA (#195) to provide incontinence care at approximately 7:15 P.M. STNA #195 stated she would get a second nurse aide to help, got busy, and forgot. The Administrator verified the resident was changed at approximately 3:15 P.M., and Resident #05 asked to be changed at approximately 6:30 P.M. The resident refused at approximately 6:45 P.M. and asked to be changed again at 7:15 P.M. The nurse aide forgot until later on in the night. The Administrator reported the facility had a bad staffing night, as they normally had five STNAs in the building. That night, they scheduled six STNAs to be in the building, but three called off work. STNA #195 was the only nurse aide working to provide care for 26 residents. During an interview on 12/11/23 at 9:20 A.M. with Resident #05, the resident reported waiting prolonged periods of time for incontinence care to be provided on many occasions. The resident reported he had had enough on the particular day of 11/18/23 and called someone to tell them what had happened. During the interview, Resident #05 stated you should not have to go out on the floor to ask someone to come help. During an interview on 12/11/23 at 2:18 P.M. with STNA #195, STNA #195 reported she came into work on 11/18/23 at 7:00 P.M., Resident #05 approached her soon after and stated he had not been changes, and asked STNA #195 to assist him. STNA #195 stated he wanted to get shift report first, and then forgot to return to provide incontinence care to Resident #05. Resident #05 later again approached STNA #195 and asked to be changed. STNA #195 told Resident #05 she was working by herself, and could not change him at that time. STNA #195 reported she was the only nurse aide on the floor that night, and just did not have enough time to get to Resident #05. STNA #195 reported she finally remembered to change the resident, possibly around midnight, and went to his room and provided incontinence care. Upon finishing and leaving Resident's #05 room, STNA #195 saw Resident #05's daughter coming out of the elevator. Review of the facility policy titled, Perineal Care, revised October 2010, revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The deficiency was corrected on 11/20/23 after the facility implemented the following corrective actions: • On 11/19/23, the Assistant Director of Nursing (ADON) assessed Resident #05 with no concern noted. • On 11/19/23, the Administrator and Social Service Director #650 interviewed Resident #05. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 12 of 14 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 12/18/2023 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 On 11/19/23, the Administrator/designee interviewed all staff who may have worked with Resident #05 during the time period in question. • On 11/19/23, the Administrator/designee interviewed all residents residing in the facility with no additional concerns identified. • On 11/19/23, the nursing management team assessed all residents residing in the facility with no concerns identified. • On 11/19/23, the Administrator/designee educated all staff on informing their charge nurse immediately of any resident refusals in care. • On 11/19/23, the Administrator/designee educated all staff on working together to meet resident needs, nurses helping the nurse aides, pulling staff from other floors if necessary, and contacting the DON or Administrator for further guidance if needed. • On 11/19/23, the Administrator/Designee educated Scheduler #655 on staffing protocols. • Beginning on 11/19/23, the Administrator/DON conducted staffing audits once per shift on each shift for six shifts, followed by three times weekly for one week, followed by two times weekly for two weeks, and then as needed. No concerns with the audits were identified. • On 11/20/23, the Administrator/designee educated all staff on the abuse and neglect protocol. • On 11/20/23, the Regional Director of Operations #907 educated the Administrator and DON regarding staffing protocols. This deficiency represents non-compliance investigated under Complaint Number OH00148544. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 13 of 14 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 12/18/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of a facility self-reported incident (SRI), and review of the facility investigation, the facility failed to maintain adequate staffing to ensure a resident's preferred bathing schedule was honored. This affected one (#09) of three residents reviewed for activities of daily living (ADLs). The facility census was 65. Findings include: Review of the medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with foot ulcer, cellulitis, heart disease, dysphagia, arthritis, pain in left foot, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/23, revealed Resident #09 was cognitively intact. The resident was dependent on staff assistance for toileting, bathing, dressing, and putting on/taking off footwear. The resident had a diabetic foot ulcer with applications of ointments/medications and dressings to feet. Review of the plan of care, revised 10/09/23, revealed Resident #09 had an ADL self-care performance deficit related to disease process. The resident required staff assistance to complete ADL tasks daily. Interventions included resident requiring extensive assistance of one staff with shower two times per week and as needed. Review of Resident #09's ADL report revealed the resident preferred bathing on day shift on Mondays and Thursdays. Further review revealed on Monday, 12/04/23, the ADL question for Resident #09 receiving a bath or shower was documented as both yes and not applicable. There was no bathing documentation for 12/05/23. Review of the facility SRI dated 12/05/23 at 11:10 A.M., and review of the corresponding investigation, revealed Resident #09 received a shower on 12/05/23 between 2:30 A.M. and 2:45 A.M. During an interview on 12/07/23 with State Tested Nurse Aide (STNA) #195, the staff member reported working from 7:00 P.M. on 12/04/23 through 7:00 A.M. on 12/05/23. STNA #195 confirmed upon arriving for her shift, she was informed in report that Resident #09 had not received his scheduled shower on 12/04/23 due to staffing issues. When Resident #09 activated his call light sometime after 2:00 A.M. on 12/05/23 to request assistance to the bathroom, STNA #195 stated she knew the resident had not received his scheduled shower, so she offered to give him one. The resident agreed, and STNA #195 proceeded to give him a shower between 2:30 A.M. and 2:45 A.M. During an interview on 12/11/23 at 8:50 A.M. with Resident #09, the resident reported he had not received a shower on 12/04/23. The resident reported STNA #195 was trying to help out by giving him a shower later on in the night. Resident #09 reported it was not unusual to receive a shower late at night. This deficiency represents an incidental finding discovered during investigation under Complaint Number OH00148949. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365418 If continuation sheet Page 14 of 14