Inspection·September 19, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood pressure of 144/62 and oxygen of 95% on room air. Resident #22 was found on the floor next to the bed, stated she was reaching for the remote, did hit head when fell on bedside table handle causing a 4 (four) centimeter (cm) laceration to the left side of her head, cleansed and applied bacitracin, no other injuries noted, resident is not on blood thinners and neurochecks are within normal limits.- NP #105 responded with: any change in mental status? Is patient able to recall the event? Any complaints of pain anywhere? Any cuts, abrasions, bruising, or open areas due to fall or any bleeding? How is range of motion (ROM)? Is patient able to flex and bend extremity? Any swelling to extremity or joint? Is patient on a blood thinner? How is pupil reactivity to light? Any difficulty breathing or shortness of breath? Any sweats, nausea, headache or chest pain?- LPN #107: No changes in mental status, able to recall event, ROM is per resident's normal, extremities move well, pupil reactions is good, no other symptoms and not on a blood thinner.- NP #105: New order for laceration, cleanse site with warm water and soap daily, pat dry, apply steri-strips to area, monitor vital signs every 4 hours for 24 hours, neurochecks per facility protocol, notify of any increase in lethargy, change in mental status or difficulty with following commands, continue to monitor patient and vital signs, continue to follow facility protocol and follow up with primary care provider. Interview on 09/19/25 at 12:51 P.M. with Certified Nursing Assistant (CNA) #113 revealed Resident #22 had an incident where she was not sent out to the hospital until after six hours after her head was injured and still bleeding. CNA #113 stated she had been assigned to the memory care unit but she was taking her residents out to church then helped the aides on the long term unit when she heard screaming. CNA #113 stated there were only two nurses in the building and they had four halls to cover and the nurse for Resident #22's hall was on the memory care unit. CNA #113 stated another aide stayed with Resident #22 while she went to memory care to send the nurse (LPN #107) to help the resident and due to only CNA #113 and LPN #107 being assigned to memory care, CNA #113 had to stay on the unit to supervise the residents while LPN #107 assisted Resident #22. CNA #113 stated the fall happened at about 10:15 A.M. and LPN #107 returned to the memory care unit at about 11 A.M. because lunch was coming out to be served. CNA #113 stated neither she nor LPN #107 left the memory care unit until approximately 2 P.M. CNA #113 stated she checked on Resident #22 at 2 P.M. and her head was still bleeding and she could no longer remember where she was anymore. CNA #113 stated she notified LPN #107 and thought she had gone to help, but CNA #113 was then contacted by Registered Nurse (RN) #100 who stated if she need anything while LPN #107 was gone to let him know. CNA #113 stated she asked RN #100 about Resident #22 and he did not know what she was talking about. CNA #113 stated Resident #22 did not have a bandage or anything on her head, just a salve and Resident #22 had received 4 staples when she went out to the hospital. Observation on 09/19/25 at 1:13 P.M. revealed Resident #22 was sleeping in her bed. She had non-skid strips on the floor underneath her bed on the right side instead of on the left side of the bed per care plan and there was no dycem underneath the cushion of her wheelchair. Interview on 09/19/25 at 1:16 P.M. with RN #100 revealed he was called to Resident #22's room to help because she had fallen. Resident #22 had hit her head and it was bleeding, Resident #22 was assessed for severe injury and then the doctor was contacted. RN #100 stated the instructions were to keep Resident #22 onsite and watch her per the fall protocol and neurochecks. RN #100 stated later in the day, LPN #107 was on break and Resident #22's family was visiting and requested he evaluate her. RN #100 stated Resident #22's left eye was pin-point and fixed so he let the on-call doctor know and sent Resident #22 to the emergency room. Observation and interview on 09/19/25 at 1:40 P.M. with Hospitality Aide (HA) #115 confirmed Resident #22's non-skid strips were not in place to the left of her bed and there was no dycem in her wheelchair seat per the plan of care. Interview on 09/19/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 2 of 4 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1:45 P.M. with Resident #22's responsible party (RP) revealed after noon, she came to the facility to see Resident #22 and was immediately approached in the hallway by a nervous-looking LPN #107 who informed her Resident #22 had fallen earlier in the shift and hit her head but was doing well. RP stated Resident #22 was in her wheelchair in the dining room when she arrived, so she went to sit with her. A glob of salve was on the wound, but it appeared the wound was bleeding through the salve. RP stated Resident #22 was initially okay with recalling the event, then an aide approached after a while and Resident #22 could not long recognize RP. RP stated Resident #22 told her she was confused, and because she figured Resident #22 would need to go to the hospital soon, RP ran home to take care of something and before she came back, CNA #113 had called and stated Resident #22's memory was getting worse. When RP returned approximately twenty minutes later, Resident #22 had been put in her recliner in her room, and her head appeared to be seeping blood and the recliner was soaked. RP stated no one had done neurochecks during her initial visit and when she had returned to the facility, LPN #107 wasn't there so RN #100 checked on Resident #22 and sent her to the emergency room. Interview on 09/19/25 at 2:26 P.M. with LPN #107 revealed Resident #22 rolled out of bed reaching for something that had fallen on the floor so she and RN #100 assessed her immediately because they heard her fall. LPN #107 stated Resident #22's neurochecks were good, vitals were good, and they cleaned the blood the best they could and assessed for other injuries. LPN #107 stated the gash to Resident #22's head was hidden in her hair but she didn't think it looked deep. LPN #107 stated they helped Resident #22 off the floor and got her back into bed, she notified the physician and family and continued neurochecks throughout the day. LPN #107 admitted despite charting she contacted the family at the time of the incident, she did not contact them right away and it may have been a couple hours later because the fall happened in the middle of medication pass. LPN #107 stated she tries to contact family members as soon as she gets the time to do it. LPN #107 stated she had left the building later in the day to get a catheter for another resident and she thought she might have missed a neurocheck for Resident #22 during the time and probably should have asked RN #100 to cover it for her. LPN #107 stated she came back to the facility and RN #100 had examined Resident #22 at her family's request and noticed her left eye was fixed and he was sending her to the hospital. LPN #107 stated Resident #22's eye did look a little different. LPN #107 stated Resident #22 came back to the facility the same day with 4 staples in her head. Interview on 09/19/25 at 3:02 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed family should be contacted as soon as the resident is stable and the physician has been notified because they need to be aware of new orders and participate in care decisions. DON stated it does not matter if medication pass is interrupted, the urgent incident takes precedence and needs to be addressed completely prior to returning to routine tasks. DON and ADON confirmed NP #105 entered a progress note with an order for Resident #22 to have steri-strips in place to her head injury. Interview on 09/19/25 at 3:02 P.M. with Resident #22 revealed she could recall she had a fall because she went to pick something up and rolled out of bed. Resident #22 said her head hurt because she hit it during the fall and ended up with these in her head (while indicating to the wound). Resident #22 stated she could not recall if she was confused after the fall or not but she recalled getting staples and thought she still had them. During the interview, an observation was made of Resident #22's recliner and there was a fist-sized stain on the chair where her head would have been laying after being placed in the recliner. Interview on 09/19/25 at 3:10 P.M. with LPN #111 revealed she was the manager on call at the time of the incident. LPN #111 stated RN #100 notified her of the incident while LPN #107 cared for Resident #22. LPN #111 stated she was made aware neurochecks were good, her head was initially bleeding but was stopped quickly, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 3 of 4 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wound was cleaned, and they placed bacitracin on the wound because they couldn't place a dressing on her head due to her hair. LPN #111 stated later in the day she was called by RN #100 again because Resident #22's left eye was fixed and he wanted to send her to the emergency room. Resident #22 returned the same day. Review of an undated policy titled Notification of Physician and Family revealed the physician and family will be notified of change in condition after any incident/accident involving the resident which results in an injury or any fall; a significant change in mental or psychosocial status in a life-threatening condition or clinical complication; a need to alter treatment; a decision to transfer or discharge; a change in room or roommate; any change or medical condition which in the professional judgment of the staff requires notification; and any bruise or injury of unknown origin. This deficiency represents non-compliance investigated under Complaint Number 2611114. Event ID: Facility ID: 365431 If continuation sheet Page 4 of 4