Health inspection·December 21, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure residents and responsible parties were provided a notice of transfer upon transfer from the facility. This affected two (#13 and #51) of two residents reviewed for hospitalizations. The facility identified three residents transferred to the hospital in the past 90 days. The facility census was 48. Findings include: 1. Review of the medical record for Resident #51 revealed the resident was admitted to the facility on [DATE]. Diagnoses include morbid obesity, heart failure hypertensive heart disease, chronic kidney disease stage III, and coronary artery disease. Review of the progress note, dated 09/30/21 at 12:23 P.M., revealed Resident #51 was short of breath and gasping for air, with low oxygen levels. The emergency squad was called and the resident was taken by squad to local hospital. Review of the medical record revealed there was no notice of discharge provided to the resident or responsible party upon transfer to the hospital or as soon as practicable after transfer. Interview with Business Office Manager #242 on 12/20/21 at 2:25 P.M. verified the resident and responsible party were not provided a notice of discharge upon transfer to the hospital or as soon as practicable afterwards. 2. Review of the medical record for Resident #13 revealed an admission date of 10/06/21. Diagnoses included morbid obesity with alveolar hypoventilation, type II diabetes mellitus with diabetic chronic kidney disease, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 10/13/21, revealed Resident #13 had moderate cognitive impairment. Review of the medical record for Resident #13 revealed Resident #13 was transferred from the facility on 10/29/21 and 11/27/21. Review of the medical record revealed there was no documentation of the resident's representative of receiving written notice for the reason for the transfer from the facility. Interview on 12/21/21 at 8:00 A.M. with the Administrator verified Resident #13's representative did not receive written notice for the transfer from the facility on 10/29/21 and 11/27/21. Review of the facility's policy titled Admission, Discharge and Transfer, dated 05/30/19, revealed a resident and responsible party were to be notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood. The written notice was to include a statement of the resident's appeal rights, including the name of the entity which received appeal requested, the address of the entity, the telephone number of the entity which received such requests information on how to obtain an appeal form, assistance in submitting the appeal hearing request, and the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. the notice of transfer or discharge must be made by the facility at least 30 days before the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Healthcare Center 924 Charlie's Way Montpelier, OH 43543 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 0623 was transferred or discharged or as soon as practicable before transfer or discharge when an immediate transfer or discharge was required by the resident's urgent medical needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Healthcare Center 924 Charlie's Way Montpelier, OH 43543 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure residents were provided with bed hold notices upon transfer from the facility. This affected one (#13) of two residents reviewed for hospitalizations. The facility identified three residents discharged to the hospital in the last 90 days. The facility census was 48. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/06/21. Diagnoses included morbid obesity with alveolar hypoventilation, type II diabetes mellitus with diabetic chronic kidney disease, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 10/13/21, revealed Resident #13 had moderate cognitive impairment. Review of the medical record for Resident #13 revealed Resident #13 was transferred from the facility on 10/29/21 and 11/27/21. Review of the medical record revealed there was no documentation of the resident and resident representative of receiving a bed hold notice from the facility on 10/29/21 and 11/27/21, when Resident #13 was transferred to the hospital. Interview on 12/21/21 at 8:00 A.M. with the Administrator verified Resident #13 did not receive a bed hold notice for the transfer/discharge from the facility on 10/29/21 and 11/27/21. Review of the facility's policy titled Bed Hold Policy, dated 05/30/19, revealed the facility was to obtain proper authorization to hold a resident bed when the resident returned to the hospital of went on a leave. The bed hold authorization could be signed prior to the patient leaving the building or within 24 hours of the resident leaving the facility or the following business day if the resident left on a weekend of holiday. If a resident returned to the hospital, the Admissions director or designee was to notify the resident and/or responsible party of the days available under their Medicaid benefits or the private pay cost associated with holding the bed, within 24 hours of the patient leaving the facility or the following day if the patient left on the weekend or holiday. The nurse or designee was to obtain the residents or responsible party signature on the bed hold authorization form each time the resident leaves on a bed hold. If the form could not be signed prior to the resident leaving and needed to be mailed, it must be mailed certified return receipt requested by the business Office Manager or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Healthcare Center 924 Charlie's Way Montpelier, OH 43543 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on medical record review, resident interview, staff interview, and policy review, the facility failed to provide a copy of the baseline care plan to a resident and their representative. This affected one (Resident #251) of thirteen residents reviewed for care plans. The facility census was 48. Findings include: Review of the medical record for Resident #251 revealed an admission date of 12/17/21. Diagnoses included chronic kidney disease, bipolar disorder, congestive heart failure, essential hypertension, schizoaffective disorder and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment revealed it had not yet been completed. Review of the medical record revealed a baseline care plan was completed on 12/17/21 for Resident #251. The baseline care plan was not signed by Resident #251 or their representative as indicated on the care plan. Interview on 12/19/21 at 2:34 P.M. with Resident #251 revealed he never received a copy of his baseline care plan. Interview on 12/21/21 at 11:10 A.M. with the Director of Nursing verified Resident #251 or their representative received a copy of the baseline care plan. Review of the policy titled Baseline Care Plan, revised 07/01/21, revealed the facility will provide a copy of the baseline care plan or summary to the resident and resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Healthcare Center 924 Charlie's Way Montpelier, OH 43543 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to provide care and services to monitor a vascular access for a resident that received dialysis. This affected one (Resident #251) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis in the facility. Residents Affected - Few Findings include: Review of the medical record for Resident #251 revealed an admission date of 12/17/21. Diagnoses included chronic kidney disease. Review of the care plan revealed Resident #251 was currently on dialysis therapy for chronic kidney disease stage four. Interventions included dialysis on Tuesday, Thursday and Saturday at 11:00 A.M. Type of dialysis access site was a right permanent catheter. Evaluate the resident following dialysis treatment. Hemodialysis port-if port was located in arm, do not complete blood draws, blood pressures in same arm. Do not remove dressing applied by dialysis center. Evaluate port for bleeding. If bleeding occurs, apply continuous direct pressure to site for at least five minutes, if unable to stop the bleeding call 911. Report abnormal findings to medical provider, nephrologist/dialysis center, resident, and resident representative. Review of Resident #251's physician orders, dated 12/17/21, revealed to perform pre and post dialysis assessment every Tuesday, Thursday and Saturday. Review of Resident #251's medical record revealed there was no documentation of monitoring the dialysis access. Interview on 12/21/21 at 9:59 A.M. with the Director of Nursing verified there was no documentation of monitoring of the vascular dialysis access. Review of the facility's policy titled Hemodialysis Care and Monitoring, revised 03/23/18, revealed care plans will be updated to reflect individual vascular access device care and monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Healthcare Center 924 Charlie's Way Montpelier, OH 43543 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and policy review, the facility failed to administer medications as ordered by the physician with a medication error rate of less than five percent (%). There were three medications errors out of 26 opportunities resulting in a 11.5% medication error rate. This affected two (Resident #4 and #14) of four residents observed for medication administration. The facility census 48. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 07/09/20. Diagnoses included Parkinson's Disease and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/03/21, revealed Resident #4 was cognitively intact. Review of Resident #4's physician orders, dated 07/10/20, revealed an order for calcium carbonate-vitamin D (supplement) 500 milligrams (mg)/200 units one tablet twice a day. Observation on 12/20/21 at 8:09 A.M. of Licensed Practical Nurse (LPN) #206 administer medications to Resident #4 revealed LPN #206 administered calcium with vitamin D 600 milligram (mg)/10 microgram (mcg) one tablet to Resident #4. Interview on 12/20/21 at 8:12 A.M. with LPN #206 verified she administered calcium with vitamin D 600 mg/10 mcg one tablet to Resident #4 and not the physician ordered calcium carbonate-vitamin D 500 mg/200 units one tablet. 2. Review of the medical record for Resident #14 revealed an admission date of 06/10/21. Diagnoses included primary generalized osteoarthritis and hypothyroidism. Review of the quarterly MDS assessment, dated 10/05/21, revealed Resident #14 was cognitively intact. Review of Resident #14's physician orders, dated 11/04/21, revealed an order for os-cal (supplement) tablet chewable 500 mg - 600 unit give one tablet by mouth twice a day and Pepcid (antacid) 10 mg two tablets twice a day. Observation on 12/20/21 at 8:19 A.M. of Licensed Practical Nurse (LPN) #206 administer medications to Resident #14 revealed LPN #206 administered calcium with vitamin D 600 mg/10 mcg one tablet and Pepcid 10 mg one tablet to Resident #14. Interview on 12/20/21 at 9:27 A.M. with LPN #206 verified she administered calcium with vitamin D 600 mg/ 10 mcg one tablet and Pepcid 10 mg one tablet to Resident #14. LPN #206 verified Resident #14's physician order was Pepcid 10 mg two tablets and os-cal chewable tablet 500 mg - 600 units one tablet. Review of the facility's policy titled Liberalized Medication Administration, revised 04/28/21, revealed the general nursing standards of practice for medication administration will remain in place including the Five Rights of medication administration, maintaining infection control standards for medication administration, and maintaining resident dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Healthcare Center 924 Charlie's Way Montpelier, OH 43543 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #30's medical record revealed an admission date of 04/21/20. Diagnoses included chronic kidney disease. Review of Resident #30's Minimum Data Set (MDS) assessment, dated 11/08/21, revealed Resident #30 was severely cognitively impaired and Resident #30 had an indwelling catheter. Residents Affected - Few Observations on 12/19/21 at 9:30 A.M. and at 9:55 A.M. of Resident #30 revealed Resident #30 was lying on his side in his bed. Resident #30's catheter bag was observed uncovered, on the floor, partially full of dark yellow urine and visible from the hallway. Interview on 12/19/21 at 10:00 A.M. with Licensed Practical Nurse (LPN) #275 verified Resident #30's catheter bag was uncovered, lying on the floor, and visible from the hallway. Review of the facility's policy titled Catheter Drainage Bag and Tube Maintenance, revised 04/20/17, revealed drainage bags would not be placed on the floor. Based on record review, observation, staff interview, and policy review, the facility failed to administer eye drops using appropriate infection control practices. This affected one resident (#33) of two residents observed for eye drops. In addition, the facility failed to ensure residents with indwelling catheters had their catheters managed in a sanitary manner. This affected one (#30) of two residents the facility identified as having indwelling catheters. The facility census was 48. Findings include: 1. Observation and interview on 12/20/21 at 7:53 A.M. of Licensed Practical Nurse (LPN) #206 revealed LPN #206 administered medications to Resident #33. LPN #206 administered eye drops to Resident #33 without washing her hands or wearing gloves prior to administration. LPN #206 verified she did not wash her hands prior to administering the eye drops and did not wear gloves. LPN #206 stated she was not aware that she had to wear gloves. Review of the facility's policy titled Liberalized Medication Administration, revised 04/28/21, revealed the general nursing standards of practice for medication administration will remain in place including the Five Rights of medication administration, maintaining infection control standards for medication administration, and maintaining resident dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 8 of 8