Health inspection·January 18, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #246's progress notes revealed on 10/04/22 at 9:17 P.M. Resident #246's blood sugar was down to 56 and she was given a peanut butter sandwich. At 9:45 P.M. Resident #246's blood sugar continued to be low, reading 58. Yogurt and a health shake were given. On 10/04/22 at 10:13 P.M. Resident #246's blood sugar was 70 and she reported she started to feel better. On 10/05/22 at 6:25 A.M. Resident #246's blood sugar was 171. No notification to the physician was found when Resident #246's blood sugar dropped below the parameter of 60 on 10/04/22. Interview on 01/11/23 at 3:57 P.M. with the Administrator verified the Director of Nursing (DON) reviewed Resident #246's chart and was unable to find a physician notification for when Resident #246's blood sugars dropped below 60 on 10/04/22. 3. Review of the medical record of Resident #243 revealed an admission date of 08/18/22 and a discharge date of 08/27/22. Diagnoses included peritoneal abscess, quadriplegia neuromuscular dysfunction of bladder, and overactive bladder. Review of the physician orders revealed an order dated 08/18/22 for Resident #243 to be straight catheterized as needed. On 08/22/22 a urinalysis was ordered. Review of the urinalysis ordered on 08/22/22 revealed a specimen was obtained on 08/23/22 and results indicated a culture and sensitivity was indicated. The report indicted it was reported on 08/26/22 and 4:50 P.M. The progress notes were absent for any notification of the urinalysis results to the physician. An electronic mail received from Administrator on 01/09/23 at 3:31 P.M. revealed the facility failed to notify the physician of the urinalysis results. This deficiency represents non-compliance investigated under Master Complaint Number OH00138604. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 2 of 24 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 01/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on medical record review, review of a Self-Reported Incident (SRI), staff interviews, review of the local police report, review of the facility investigation, review of email and policy review, the facility failed to ensure one resident (Resident #28) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and serious negative psychosocial harm, based on a reasonable person's response of fear and anxiety, for Resident #28, who has severe cognitive impairment, when Licensed Practical Nurse (LPN) #431 physically walked Resident #28 back a couple steps to a wall, held her against the wall with her right forearm, and placed her left hand on the resident's throat in response to behaviors Resident #28 was exhibiting, causing Resident #28 to start screaming and crying. This affected one (#28) of four residents (#10, #20, #28, and #30) reviewed for abuse. There was a total of 17 residents (#28, #38, #20, #293, #143, #39, #8, #30, #10, #14, #1, #26, #27, #15, #25, #19, and #36) screened for abuse during the annual survey. The facility census was 44. On 01/09/23 at 4:01 P.M., the Licensed Nursing Home Administrator (LNHA), Regional Director of Clinical Operations (RDCO) #503, and Regional Director of Operations (RDO) #510 were notified Immediate Jeopardy began on 12/29/22 at approximately 9:20 A.M. when Resident #28 was at LPN #431's nurse's medication cart and attempted to take the narcotic book. LPN #431 attempted to direct Resident #28 away from the cart by telling her no and pushing her hand away from the book. Resident #28 became agitated and grabbed LPN #431's face, neck, and face mask. LPN #431 responded by raising her forearm and walking Resident #28 back a couple steps to the wall then holding the resident against the wall with her right forearm across Resident #28's chest and her left hand on Resident #28's throat. State Tested Nursing Assistant (STNA) #422 witnessed the interaction from the point of Resident #28 grabbing the narcotic book, observing LPN #431 raise her right forearm and backing Resident #28 into the wall, placing her forearm on the resident's chest and her hand on Resident #28's neck to hold her there. The thud sound from Resident #28 being backed against the wall caused STNA #420 to turn around and she also witnessed LPN #431 pinning Resident #28 to the wall with her right forearm and left hand on her neck. The Immediate Jeopardy was removed on 01/10/23 when the facility implemented the following corrective actions: • On 12/29/22 at 9:23 A.M., Resident #28 and LPN #431 were immediately separated by STNA #422 and Activities Director (AD) #442. Resident #28 was placed on a one-on-one supervision level by nursing staff. • On 12/29/22 at 9:25 A.M., the Director of Nursing (DON) was alerted of the situation and notified RDCO #503. LPN #431 was removed from patient care area and went with RDCO #503 to the DON's office. • On 12/29/22 at 9:30 A.M., Medical Director #600 was notified by the DON and a new order was placed for Resident #28 to be placed on a one-on-one supervision level. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 3 of 24 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 01/18/2023 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 0600 • Level of Harm - Immediate jeopardy to resident health or safety On 12/29/22 at 9:45 A.M., Resident #28 had skin assessments and pain assessments completed by the DON with no findings of any injuries. Neurological checks were initiated by the DON. • Residents Affected - Few On 12/29/22 at 10:04 A.M., RDCO #503 began an investigation, obtaining LPN #431's statement. LPN #431 was suspended from duty pending investigation by the Administrator, RDCO #503, the DON and Human Resources Manager (HRM) #446. The DON escorted LPN #431 to the time clock and to the exit door. • On 12/29/22 at 10:30 A.M., Social Services Director (SSD) #435 and the Administrator notified Resident #28's representative/husband, of the altercation that took place with LPN #431. • On 12/29/22 at 11:00 A.M., the Administrator and STNA #422 attempted to obtain a statement from Resident #28. • On 12/29/22 at 11:28 A.M., the initial SRI was submitted to the Ohio Department of Health by the Administrator. • On 12/29/22 at 1:00 P.M., all residents on the North and South halls, where LPN #431 was assigned, were asked the abuse questionnaire by the Administrator. No negative findings were discovered. • On 12/29/22 at 2:30 P.M., employee statements were obtained by the Administrator. • On 12/29/22 at 3:00 P.M., the DON completed skin assessments for all residents on the North and South halls for residents who were not able to be interviewed. No negative findings were discovered. • On 12/29/22 at 3:00 P.M., the Administrator completed education for all facility staff on the facility's Abuse, Neglect, and Misappropriation policy and the de-escalation of Alzheimer's and dementia residents. • On 01/03/23 at 10:00 A.M., the Administrator notified the Montpelier Police Department of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 4 of 24 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 01/18/2023 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 0600 incident. Level of Harm - Immediate jeopardy to resident health or safety • On 01/04/23, the final SRI was submitted to the Ohio Department of Health by the Administrator at 6:31 P.M. Residents Affected - Few • On 01/09/23 at 2:22 P.M., LPN #431 was terminated from the facility by the Administrator, DON, and HRM #446. • On 01/09/23, the facility-initiated audits to be completed for abuse and de-escalation practices of Alzheimer's and dementia residents. Three staff will be questioned about their knowledge, three times weekly, for four weeks to be completed by the DON. • On 01/10/23, the residents on the East Hall were interviewed for abuse by the Administrator and skin assessments were performed by the DON. No negative findings were discovered. • On 01/13/23, a Quality Assurance meeting was scheduled to be held to review the audit findings and adjust as needed. • Starting 12/27/22 through 01/10/23, the records of three additional residents (#10, #20, and #23) were reviewed for abuse. Sixteen additional residents (#38, #20, #293, #143, #39, #8, #30, #10, #14, #1, #26, #27, #15, #25, #19, and #36) were screened for abuse during the annual survey. There were no additional concerns noted. Although the Immediate Jeopardy was removed on 01/10/22, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #28's medical record revealed an admission date of 11/12/22. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, type II diabetes, anxiety disorder, depression, and insomnia. Review of Resident #28's Minimum Data Set (MDS) assessment, dated 11/19/22, revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #28 had severe cognitive impairment. Resident #28 had delusions and displayed physical behavioral and verbal symptoms directed toward (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 5 of 24 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 01/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few others, behavioral symptoms not directed toward others, and wandering behaviors one to three days during the review period. It was noted Resident #28's wandering behaviors significantly intruded on the privacy and activities of others. Review of Resident #28's care plan, revised 12/29/22, revealed supports and interventions for behavioral problems. Interventions included one-on-one staffing, fifteen minute checks as ordered, approach and speak in a calm manor, behavioral consult as needed, encourage resident to express her feelings, consult with psychiatric services, encourage to participate in activities, honor resident's choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks to divert attention, monitor behavioral episodes and attempt to determine underlying cause, observe and anticipate needs, and praise any indication of progress in behaviors. Review of Resident #28's progress notes revealed a late entry was completed on 01/05/23 that noted on 12/29/22 at 9:20 A.M. it was alleged Resident #28 was in the hallway with LPN #431, when Resident #28 reached for narcotic book. LPN #431 stated to Resident #28 that was her narcotic book and removed Resident #28's hand from the book. Resident #28 then became agitated, reached for LPN #431's facemask ripping the mask, and then attempted to aggressively grab LPN #431 on the neck. LPN #431 used her forearm to push the resident back, however, there was a wall behind the resident, which stopped the motion. It was alleged at this time that LPN #431 utilized her other hand and placed it on the resident's chest/throat area. At this time, Resident #28 yelled out, STNA and activities director immediately separated Resident #28 and LPN #431. Resident #28 was assessed for injury by nursing staff. Neurological checks were initiated as the resident would allow/tolerate related to advanced dementia, behaviors and agitation. Resident #28 was immediately placed on one-on-one supervision by staff and assisted to a calm environment to participate in one-on-one activity. Resident #28's physician was notified of the incident. Resident #28's husband was notified of the incident. Review of the facility SRI, dated 12/29/22, revealed LPN #431 reported Resident #28 attempted to touch her face and ripped her mask off. Resident #28 then placed her hands around LPN #431's neck. LPN #431 attempted to separate and loosen her grip by using her forearm to move her back towards the wall. Resident #28's head made contact with the wall. The DON heard a yell from the incident and came out to help separate the two parties. LPN #431 was escorted to an office to get her statement. Her statement was obtained, and she was walked to the nurse's station to count off medications and then walked out of the facility. LPN #431 was suspended pending investigation. Resident #28 was separated from LPN #431 and had a skin assessment completed immediately with no injuries noted. Resident #28 was placed on a one-on-one with a staff member. The Interdisciplinary Team consulted with Resident #28's family to make a referral to an older adult psychiatric unit to help adjust her medications and assist with her behavior. All interviews and skin assessments to be completed as necessary. Further review of the SRI investigation found on 12/29/22 at approximately 9:30 A.M., it was reported that LPN #431 had moved Resident #28 against the wall with her forearm. The incident occurred on North Hall and was partially witnessed by some of the nursing staff. The incident occurred as Resident #28 attempted to take LPN #431's narcotic book. LPN #431 stated she put her hand on the book to attempt to stop the resident from taking it. This upset Resident #28 and Resident #28 ripped LPN #431's mask off and placed her hand on LPN #431's neck. LPN #431 stated she then used her forearm to move Resident #28 towards the wall to keep Resident #28 from choking her. LPN #431 stated she did not at any point use her other arm to touch Resident #28. Staff statements showed LPN #431 had used her forearm to move Resident #28 towards the wall. One employee, STNA #422, stated she had seen this occur and also stated LPN #431 had placed other her hand on Resident #28's neck. Other staff witnesses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 6 of 24 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 01/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety did not see LPN #431 place her hand on Resident 28's neck. Upon interview with Resident #28, it was noted that she was very pleasant and did not have any complaints of pain. The incident was reported to the local Police Department and the officer obtained information to create a report and notified the Administrator she would contact her with an update and a copy of the report. The SRI revealed as a result of the investigation, the facility cannot substantiate the allegation of abuse stating staff interviews showed contradicting stories on how LPN #431 separated Resident #28 from herself. Residents Affected - Few Review of the STNA #420's witness statement, dated 12/29/22, revealed STNA #420 was witness to the interaction between Resident #28 and LPN #431. STNA #420 reported she heard LPN #431 say, Please stop hitting staff and Resident #28 laughing. She heard a thud and turned to see LPN #431 use her forearm to pin Resident #28 against the wall and her other hand was on Resident #28's throat. STNA #420 reported she saw STNA #422, and other staff separate them. Resident #28 was crying and screaming. Review of STNA #422's witness statement, dated 12/29/22, revealed she rounded the corner because she heard LPN #431 yelling. Resident #28 was observed grabbing the narcotic book. LPN #431 told Resident #28 No and slapped her hand away. Resident #28 then reached toward LPN #431's face. LPN #431 then choked Resident #28 with one hand and used her other arm to push Resident #28 against the wall. STNA #422 reported other staff heard the thud and yelling and ran toward them. LPN #431 then dropped her hand from Resident #28's neck but continued to pin Resident #28 against the wall. Review of the statement from LPN #431, dated 12/29/22, revealed at approximately 9:20 A.M. LPN #431 reported Resident #28 was trying to take her narcotic book. LPN #431 told Resident #28 No and She could not have it. Resident #28 had a washcloth in her hand and attempted to reach in her face and tore her mask off. LPN #431 reported Resident #28 placed her hand on LPN #431's neck and in order to loosen her grip LPN #431 moved her back with my forearm. The wall was behind her, and Resident #28 hit her head on the wall and yelled out. The DON came out to assist and immediately intervened and asked other staff members to assist with Resident #28. The DON and regional nurse then asked LPN #431 for her statement and took her to the office. LPN #431 was informed a formal investigation would be completed and asked her to not discuss this investigation outside of the interview. The facility told LPN #431 they would notify her with an outcome as soon as possible. Review of the statement from the DON revealed she was in her office when she heard yelling. She ran into the hallway and saw LPN #431 standing in front of Resident #28, who was pinned against the wall by LPN #431. LPN #431 had her right arm against Resident #28's chest and her left hand was coming down from the area of Resident #28's neck. As the DON got closer, STNA #420 stated, She can't hold her against the wall like that! LPN #431 stepped away from Resident #28 who was yelling Oh Lord just take me. Why? Why me? Resident #28 was observed holding her head and her throat as she walked. STNA #422 was walking with Resident #28 attempting to calm her and assisted her back to her room. Notification was made to RDCO #503. LPN #431 was immediately brought into the DON's office and her statement was taken. The DON then walked LPN #431 out of the facility. Review of the statement from RDCO #503 revealed she was in the DON's office when yelling was heard. The DON went out and came back in indicating she needed RDCO #503's help. The DON explained Resident #28 had been experiencing increased behaviors related to dementia aggravated by a urinary tract infection. Resident #28 had ripped LPN #431's facemask off and had tried to choke her. LPN #431 then pinned Resident #28 against the wall. LPN #431 was directed to the DON's office and the Unit Manager was directed to complete a skin assessment on Resident #28 and initiate one-on-one supervision for the resident. LPN #431's statement was taken, and LPN #431 had no observed scratches or redness. RDCO #503 explained to LPN #431 she would be suspended pending the investigation. The DON then escorted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 7 of 24 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 01/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few LPN #431 to gather her things, to the timeclock, and out of the facility. Statements were gathered from employees and residents who were able to be interviewed on the hallway. Residents who were not able to complete an interview had skin checks completed. Social Services interviewed Resident #28 for any adverse psychosocial effects, and none were noted. Review of the investigation revealed statements were taken from Activities Director (AD) #442, Registered Nurse (RN) #447, Activities Staff (AS) #479, and STNA #500. None reported witnessing the incident between Resident #28 and LPN #431. Review of the investigation's follow up interview with STNA #422, dated 01/04/23, revealed STNA #422 was asked if she saw Resident #28 put her hands around LPN #431's neck. STNA #422 stated she did not. STNA #422 was not asked about LPN #431 having her hands around Resident #28's neck. Review of the investigation's follow up interview with LPN #431 on 01/04/23 revealed LPN #431 reported Resident #28 had ripped her mask off and put her hands around her neck. LPN #431 denied putting her hands around Resident #28's neck. LPN #431 also denied slapping Resident #28's hand away from the narcotic books. Review of an email correspondence between the Administrator and the Corporate Office revealed on 01/03/23 the Administrator requested approval for termination of LPN #431. The email request revealed during the SRI investigation two employees stated they saw LPN #431's hand on Resident #28's neck. The Administrator stated she and the DON did not feel comfortable keeping LPN #431 employed. Approval was granted 01/08/23. Interview on 01/09/22 at 7:23 A.M. with the Administrator verified the allegation of staff to resident abuse between LPN #431 and Resident #28 occurred on 12/29/22. The Administrator reported at the time of the investigation there was only one witness to LPN #431 holding Resident #28 to the wall with her hand on the resident's neck. The SRI was unsubstantiated based on LPN #431 denying the allegation and only having one witness. The Administrator reported LPN #431 had not been back in the facility and they had just received approval from the corporate office to terminate her. The reason for termination was due to her customer service not being in line with the facility's standards. They did not feel comfortable having her back in the facility. During an interview on 01/09/23 at 8:07 A.M. with the Administrator, during a review of the SRI investigation witness statements, the Administrator verified there were two STNAs who witnessed LPN #431 pinning Resident #28 to the wall with her right forearm and having her left hand on Resident #28's neck. The Administrator verified the SRI for the abuse allegation should have been substantiated based on there being two witnesses to the interaction between LPN #431 and Resident #28. Interview on 01/09/23 at 8:08 A.M. with STNA #420 verified she was witness to the interaction between LPN #431 and Resident #28. STNA #420 reported she was approximately halfway down the hallway when she heard a thud and turned around. When she turned, she saw LPN #431 had pushed Resident #28 up against the wall and was holding her there with her right forearm across Resident #28's chest and her left hand on Resident #28's throat to restrain her. STNA #420 reported she was shocked because she had never seen LPN #431 react that way before. STNA #420 stated she went right away down to the Unit Manager's office and told her to get down to the hall quickly. When the Unit Manager and the DON got to the hall, LPN #431 had removed her hand from Resident #28's throat and was still holding Resident #28 against the wall with her forearm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 8 of 24 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 01/18/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 01/09/23 at 8:16 A.M. with STNA #422 verified she was witness to the interaction between LPN #431 and Resident #28. STNA #422 reported she heard a disagreement and rounded the corner of the hallway to see Resident #28 at LPN #431's medication cart grabbing LPN #431's narcotic logbook. STNA #422 reported LPN #431 told Resident #28 No and smacked Resident #28's hand away from the logbook. STNA #422 reported Resident #28 then grabbed LPN #431's face, her face mask, and her throat area. LPN #431 then grabbed Resident #28 by the throat, pushed her back into the wall, and held Resident #28 against the wall with her left hand on her throat and her right forearm across Resident #28's chest. STNA #422 reported everyone started running toward them and LPN #431 quickly dropped her hand from Resident #28's neck. STNA #422 reported LPN #431 continued to hold Resident #28 against the wall with her right arm. STNA #422 reported she and another staff took Resident #28 back down to her room and were trying to help her calm down. LPN #431 was taken to the DON's office. Resident #28 was assessed by another nurse and as far as STNA #422 was aware Resident #28 had no physical injuries from the situation. Interview on 01/12/23 at 4:09 P.M. with LPN #431 verified she had already provided statements to the facility and to the police department. LPN #431 denied putting her hands on Resident #28. LPN #431 stated Resident #28 came at her face scratching and hitting. LPN #431 reported she had marks on her neck and face from Resident #28. LPN #431 reported she knocked Resident #28's arms away from her face and pushed her back away from her to stop Resident #28 from injuring her. LPN #431 verified she held Resident #28 against the wall for a few seconds but released her when Resident #28 started screaming and hitting her head on the wall. LPN #431 stated everyone came running when Resident #28 started to scream. Review of the employee file for LPN #431 revealed a hire date of 07/15/22. Review of the Employee Corrective Action Form Dated 01/09/23 revealed LPN #431 was provided a verbal termination notice on 01/09/23. The termination notice was requested 01/03/23 and approved by the Human Resources Division Director. The reason for the termination was listed as other: a result of SRI 230588. Review of the Time Punch Card for LPN #431 revealed on 12/29/22 she clocked in at 7:00 A.M. and clocked out at 10:04 A.M. Review of the Police Report, dated 01/04/22, revealed the police department was notified on Wednesday January 4, 2023, of a physical altercation between a nurse to a patient with severe dementia which occurred 12/29/22. The report was still under investigation. Review of the facility policy titled, Ohio Abuse, Neglect, and Misappropriation, revised 09/20/22, revealed abuse was considered a willful infliction of an injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The definition of willful means the individual acted deliberately not that the individual intended to inflict injury or harm. It was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. It was the intent of the facility to prevent the abuse, mistreatment, or neglect of residents. This deficiency demonstrates non-compliance related to Master Complaint Number OH00138604. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 9 of 24 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 01/18/2023 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 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 medical record review, staff interview, review of the facility Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure allegation of one resident shoving another resident was investigated and reported to the State Survey Agency. This affected one (#28) of four residents reviewed for abuse. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed an admission date of 11/12/22. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, type II diabetes, anxiety disorder, depression, and insomnia. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #28 was severely cognitively impaired. Resident #28 had delusions and displayed physical behavioral and verbal symptoms directed toward others, behavioral symptoms not directed toward others, and wandering behaviors one to three days during the review period. It was noted Resident #28's wandering behaviors significantly intruded on the privacy and activities of others. Review of Resident #28's care plan, revised 12/28/22, revealed supports behavioral problems. Interventions for behavior problem included fifteen minute checks as ordered, approach and speak in a calm manor, behavioral consult as needed, encourage resident to express her feelings, consult with psychiatric services, encourage to participate in activities, honor resident's choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks to divert attention, monitor behavioral episodes and attempt to determine underlying cause, observe and anticipate needs, praise any indication of progress in behaviors, and stop sign on certain other resident bedroom doors to discourage Resident #28 from going into their rooms. Review of the progress notes on 12/18/22 revealed Resident #28 went into a male resident's room and the male resident was heard saying get out of his room. The male resident was found shoving Resident #28 out of his room. Resident #28 took her baby doll and threw it has hard as possible at the male resident. Resident #28 and the male resident were assessed and no injuries were found. The situation was resolved by removing Resident #28 from the male resident's room. Review of the facility submitted SRIs revealed no SRI was completed for the 12/18/22 incident where Resident #28 was shoved out of a male resident's room. Interview on 01/04/22 at 9:40 A.M. with the Administrator verified SRIs and investigations were not completed for the incident on 12/18/22. The Administrator reported she had asked the male resident about shoving Resident #28 out of his room and he denied he shoved her. The male resident reported he just walked with her/guided her out of his room. Review of the facility policy titled, Abuse, Neglect, and Misappropriation, revised 09/20/22 revealed accurate and timely identification of any event which would place residents at risk was a primary concerns of the facility. Each occurrence of resident incident, reported allegations of abuse, neglect or misappropriation of funds would be identified and reported to the supervisor and investigated timely. Self report were to be made by the executive director to the State Survey Agency and other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 10 of 24 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 01/18/2023 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 0610 authorities as appropriate. The results of the facility's investigation will be reported to the survey agency. 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 11 of 24 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 01/18/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, record review, and review of the facility policy, the facility failed to complete neurological checks after unwitnessed falls and after a witnessed head injury. This affected three (#26, #244 and #245) of four residents reviewed for falls. The facility census was 44. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 10/04/22 with medical diagnoses of Parkinson's disease, history of falling, and oropharyngeal dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #26 had impaired cognition and had used extensive assistance of two people for all activities of daily living. He had a fall with minor injury since the previous assessment. Review of the medical record for Resident #26 revealed he had an unwitnessed fall on 10/09/22. Neurological checks were not completed after this fall. Continued review revealed a witnessed fall on 10/20/22 wherein Resident #26 Did a head dive out of his chair, did a summersault, and ended up on his coccyx. Review of the Post-Fall Evaluation dated 10/20/22 did not clarify if Resident #26 hit his head. Neurological checks were not completed. 2. Review of the medical record for Resident #244 revealed an admission date of 04/14/21 and a discharge date of 10/26/22. Medical diagnoses included presence of right artificial hip joint, Parkinson's disease, and difficulty in walking. Review of the 5-day MDS assessment, dated 10/19/22, revealed Resident #244 had intact cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and hygiene. Further review revealed he had a fall with fracture since the previous assessment. Review of the medical record for Resident #244 revealed he had an unwitnessed fall on 08/19/22 and neurological checks were not completed. 3. Review of the medical record for Resident #245 revealed an admission date of 07/09/21. Diagnoses included repeated falls, spondylosis cervical region, and unsteadiness on feet. Resident #245 discharged to another skilled nursing facility on 12/08/22. Review of the comprehensive MDS assessment, dated 10/01/22, revealed Resident #245 had impaired cognition and required extensive assistance of one person for bed mobility, transfers, dressing, hygiene, and toileting, and required limited assistance of one person for walking. Review of the medical record revealed Resident #245 had unwitnessed falls on 06/30/22, 08/08/22, and 11/11/22. Neurological checks were not completed for these falls. Further review revealed Resident #245 hit his head during a fall on 07/10/22 and neurological checks were not completed. Review of an email communication received on 01/09/23 from the Administrator confirmed neurological checks were not completed for Resident #26 on 10/09/22 and 10/20/22, for Resident #244 on 08/19/22, and for Resident #245 on 06/30/22, 07/10/22, 08/08/22, and 11/11/22. Review of the facility policy titled Fall Prevention and Management, revised 06/01/22, revealed if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 12 of 24 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 01/18/2023 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 0684 the resident hit their head or the fall was unwitnessed, neurological checks should be completed. 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 13 of 24 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 01/18/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the medical records, review of hospital records, and review of the facility policy, the facility failed to implement fall interventions for one (#26). This resulted in Actual Harm when Resident #26's bed was not placed in the low position, the resident fell out of bed and suffered a dislocated left little finger. This affected one (Resident #26) of four residents reviewed for falls. Additionally, the facility failed to ensure post-fall assessments were completed and falls were tracked on the facility's incident log. This affected three (#26, #244, and #245) of four residents reviewed for falls. The facility census was 44. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 10/04/22. Diagnoses included Parkinson's disease, history of falling, and oropharyngeal dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #26 had impaired cognition and required extensive assistance of two people for all activities of daily living. He had a fall with minor injury since the previous assessment. Review of the care plan for Resident #26 revealed he was at risk for injury related to falls. An intervention dated 10/11/22 revealed his bed should be in the low position. Review of a progress note dated 10/18/22 revealed the nurse was notified Resident #26 slid off the bed and his finger was bent at a 90 degree angle. Resident #26 reported pain in his left pinky finger and was sent to the hospital. Review of the Post Fall Evaluation dated 10/18/22 revealed Resident #26's bed was in the normal position at the time of the fall. The immediate intervention was to place the bed in the low position. Review of the hospital After Visit Summary, dated 10/18/22, revealed Resident #26 had a dislocated finger on which a splint was applied. Interview on 01/04/23 at 12:17 P.M. with the Director of Nursing (DON) confirmed Resident #26 had an intervention for a low bed at the time of the fall on 10/18/22. Further interview confirmed the Post-Fall assessment dated [DATE] revealed Resident #26's bed was in the normal position and was lowered after his fall. Additionally Resident #26 fell on [DATE] and there was no Post-Fall Evaluation completed for the fall. Interview on 01/04/23 at 12:17 P.M. with the DON confirmed Post Fall Evaluation was not completed for Resident #26's fall on 12/14/22, 2. Review of the medical record for Resident #244 revealed an admission date of 04/14/21 and a discharge date of 10/26/22. Medical diagnoses included presence of right artificial hip joint, Parkinson's disease, and difficulty in walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 14 of 24 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 01/18/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of the 5-day MDS assessment dated [DATE] revealed Resident #244 had intact cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and hygiene. Further review revealed he had a fall with fracture since the previous assessment. Review of the medical record for Resident #244 revealed he fell on [DATE] and 08/27/22. No Post Fall Evaluations were completed for the falls. Additionally, the fall on 08/27/22 was not recorded on the Incident Log. Interview on 01/04/23 at 12:17 P.M. with the DON confirmed Post Fall Evaluations were not completed for Resident #244's falls on 08/21/22 and 08/27/22. Further interview confirmed the Incident Log did not include the fall for Resident #244 on 08/27/22. 3. Review of the medical record for Resident #245 revealed an admission date of 07/09/21 with medical diagnoses of repeated falls, spondylosis cervical region, and unsteadiness on feet. Resident #245 discharged to another skilled nursing facility on 12/08/22. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #245 had impaired cognition and required extensive assistance of one person for bed mobility, transfers, dressing, hygiene, and toileting, and required limited assistance of one person for walking. Review of the medical record for Resident #245 identified falls on 07/01/22 and 09/05/22 were not recorded on the Incident Log. Resident #245 also fell on [DATE], 08/13/22, 08/16/22, and 09/05/22. No Post Fall Evaluations were completed for these falls. Interview on 01/04/23 at 12:17 P.M. with the DON confirmed Post Fall Evaluations were not completed for Resident #245's falls on 07/24/22, 08/13/22, 08/16/22, and 09/05/22. Further interview confirmed the Incident Log did not include Resident #245's falls on 07/01/22 and 09/05/22. Review of the facility policy titled Fall Prevention and Management, revised 06/01/22, revealed the facility would complete a Post Fall Assessment after every fall. Further review revealed a report should be initiated in Risk Watch. Additionally, a deep root cause investigation should be discussed during an interdisciplinary team meeting and a progress note of the discussion should be placed in the resident's chart. This deficiency represents non-compliance investigated under Master Complaint Number OH00138604 and Complaint Number OH00137173. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 15 of 24 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 01/18/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of meal tickets, and review of the medical record, the facility failed to implement weight loss supplements per physician order after a significant weight loss. This affected one (#26) of two residents reviewed for weight loss. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed an admission date of 10/04/22 with medical diagnoses of Parkinson's disease, history of falling, and oropharyngeal dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #26 had impaired cognition and required extensive assistance of one person for eating. He had a significant weight loss while not on a prescribed weight-loss regimen and he was on a therapeutically altered diet. Review of the weight history for Resident #26 revealed a weight dated 11/06/22 of 201.0 pounds and a weight dated 12/21/22 of 178.6 pounds. This reflected a significant weight loss of 11.2 percent (%) in less than two months. Review of the nutrition progress note dated 12/19/22 revealed Resident #26 had very rapid weight loss and received a dysphagia pureed texture diet with nectar thick liquids. The note included a recommendation to begin a nutrition supplement twice daily with lunch and dinner. Review of a physician order dated 12/21/22 revealed Resident #26 should receive a nutrition supplement daily with lunch and dinner. Observation 12/28/22 at 12:18 P.M. with Student Aide (SA) #414 revealed Resident #26 just finished eating lunch, and he consumed 100% of his meal. Interview at that time with SA #414 revealed no nutrition supplement was on Resident #26's tray and no nutrition supplement was written on his meal ticket. Observation on 12/28/22 at 5:57 P.M. with SA #405 revealed Resident #26 finished eating dinner and he consumed 100% of the meal. Interview at that time with SA #405 confirmed Resident #26 did not receive a nutrition supplement with his meal, and no nutrition supplement was printed on his meal ticket. Telephone interview on 12/29/22 at 11:44 A.M. with Registered Dietitian (RD) #502 confirmed she recommended nutrition supplements for Resident #26. Interview on 12/29/22 at 11:53 A.M. with the Director of Nursing (DON) revealed the nurse who enters the supplement order was responsible for notifying the kitchen of the new order. Further interview confirmed the DON entered the order dated 12/21/22 for Resident #26 to receive a nutrition supplement twice daily. Interview on 12/29/22 at 11:58 A.M. with Culinary Director #439 revealed she was unable to find a communication from nursing regarding the ordered supplement for Resident #26. Further interview revealed when CD #439 received communications, CD #439 entered the order into the kitchen's computer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 16 of 24 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 01/18/2023 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 0692 system and the supplement printed on the resident's meal ticket. CD #439 confirmed the nutrition supplement was not entered in the kitchen's computer system and therefore did not print on his ticket. 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 17 of 24 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 01/18/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician reviewed and responded to pharmacist recommendations. This affected one (#10) of five residents reviewed for unnecessary medications. The facility census was 44. Findings include: Review of Resident #10's medical record revealed an admission date of 10/21/21. Diagnoses included dementia, muscle wasting and atrophy, anxiety disorder, depression, and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) assessment, dated 10/01/22, revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #10 was moderately cognitively impaired. Resident #10 displayed no behaviors during the review period. Review of Resident #10's care plan revised 11/23/22 revealed supports and interventions for a mood problem related to depression. Review of Resident #10's physician orders revealed orders dated 11/06/21 for sertraline hydrochloride (HCL) 25 milligram (mg) in the morning with sertraline HCL 50 mg for depression. Review of Resident #10's pharmacy recommendations revealed on 02/15/22 the pharmacist recommended the physician consider decreasing Resident #10's sertraline to 50 mg in the morning. Review of Resident #10's Psychotropic Medication Evaluation form dated 03/30/22 revealed Resident #10's sertraline 25 mg and 50 mg was reviewed by the Director of Nursing (DON). No evidence of the physician reviewing the pharmacist's recommendations were found. Interview on 12/29/22 at 3:58 P.M. with the DON verified the Psychotropic Medication Evaluation for Resident #10 was signed by the previous DON but not by the physician. Interview on 01/03/22 at 9:18 A.M. with the DON revealed no additional information was found to prove the physician was provided and reviewed the pharmacist recommendation to consider a dose reduction for Resident #10's sertraline. Review of the facility policy titled Medication Regimen Review, revised 09/23/19, revealed a monthly medication review would be performed by a licensed pharmacist. The pharmacist would report any irregularities to the attending physician, the facility's medical director,the director of nursing, and these reports must be acted on in a timely manner. Urgent medications irregularities should be addressed by the attending physician the day the notification was received. Non-urgent medication irregularities would be addressed with the attending physician in a manner that meets the needs the resident but no later than their next routine visit to assess the resident or 60 days whichever is sooner. The attending physician must document in the medical director the identified irregularity had been reviewed and what, if any action had been taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 18 of 24 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 01/18/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of manufacturer instructions, review of meal times, and review of the facility policy, the facility failed to administer insulin in accordance with the manufacturer instructions for one (Resident #246) of three residents reviewed for insulin use. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #246 revealed an admission date of 09/12/22 and a discharge date of 10/05/22. Diagnoses included displaced intertrochanteric fracture of right femur subsequent encounter, type II diabetes, and morbid obesity. Review of Resident #246's Minimum Data Set (MDS) assessment, dated 09/19/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #246 was cognitively intact. Review of Resident #246's physician orders revealed an order dated 09/12/22 for Insulin Regular Human Injection Solution 100 units per milliliters (ml) inject per sliding scale. An order dated 09/22/22 for Insulin Regular Human Injection Solution 100 units per ml inject 10 units subcutaneously before meals for diabetes. Review of the administration times of Resident #246's insulin revealed Resident #246's short acting insulin was administered one hour and forty minutes to two hours and ten minutes prior to meal consumption on the following days: 09/16/22 at 5:31 A.M., 09/18/22 at 5:45 A.M., 09/23/22 at 5:20 A.M., 09/24/22 at 5:15 A.M., 09/28/22 at 5:38 A.M., 09/29/22 at 5:43 A.M., and 09/30/22 at 5:22 A.M. Review of the Manufacturer's Instructions for Insulin Regular Human Injection Solution (Humulin R) 100 units per ml revealed the insulin was short acting and was to be administered thirty minutes prior to meals. Review of the facility's mealtime schedule revealed breakfast was served at 7:25 A.M. on the hall in which Resident #246 resided. Interview on 01/05/22 at 3:02 P.M. with Regional Director of Clinical Operations Registered Nurse (RDCORN) #503 verified Resident #246's short acting insulin procedure was not completed correctly at times. Review of the facility policy titled Medication Administration, dated 2013, revealed the facility should observe the five rights in giving medication including giving the medication to the right resident, the right medicine, the right dose, the right route, at the right time. This is an example of non-compliance for Complaint Number OH00136193 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 19 of 24 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 01/18/2023 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED 02/13/23 Residents Affected - Few Based on review of the facility Self-Reported Incidents (SRI), email communication, and staff interview, the facility failed to substantiate and accurately report the results of an investigation of staff to resident abuse to the State Survey Agency. This affected one (#230588) SRI out of six SRIs reviewed. The facility census was 44. Findings include: Review of the SRI #230588, dated 12/29/22, revealed at approximately 9:30 A.M. it was reported that Licensed Practical Nurse (LPN) #431 had moved Resident #28 against the wall with her forearm. The incident occurred on North Hall and was partially witnessed by some of the nursing staff. The incident occurred as Resident #28 attempted to take LPN #431's narcotic book. LPN #431 stated she put her hand on the book to attempt resident from taking it. This upset Resident #28 and Resident #28 ripped LPN #431's mask off and placed her hand on LPN #431's neck. LPN #431 stated she then used her forearm to move Resident #28 towards the wall to keep Resident #28 from choking her. LPN #431 stated she did not at any point use her other arm to touch Resident #28. When the incident was discovered, Resident #28 was separated from LPN #431 and had a skin assessment completed immediately with no injuries noted. Resident #28 was also immediately placed on a one to one with staff members to ensure safety of other residents. Staff escorted LPN #431 into the Director of Nursing's office to obtain her statement. LPN #431 was suspended immediately and was not in contact with any resident as she was escorted out of the building. Staff statements showed LPN #431 had used her forearm to move Resident #28 towards the wall. The SRI stated one employee, State Tested Nursing Assistant (STNA) #422, stated she had seen this occur and also stated that LPN #431 had placed other her hand on Resident #28's neck. Other staff witnesses did not see LPN #431 place her hand on Resident 28's neck. Upon interview with Resident #28, it was noted that she was very pleasant and did not have any complaints of pain. Resident #28's primary diagnosis was Alzheimer's disease, unspecified. The SRI stated as a result of the investigation, the facility cannot substantiate the allegation of abuse. Staff interviews showed contradicting stories on how LPN #431 separated Resident #28 from herself. Resident #28 was shown to have a urinary tract infection at this time, and had an order for an antibiotic. Resident #28 had increased behaviors the last seven to ten days and had had a recent emergency room trip on 12/27/22. Resident #28 had also seen Senior Wellness Group for mental health services on 12/21/22. With Resident #28's husband's consent, she admitted to a geriatric mental health stabilization hospital on [DATE]. LPN #431 had not returned to the facility at this time. The SRI was marked as completed on 01/04/23. Review of the Witness Statements from the 12/29/22 SRI investigation revealed STNA #420 was witness to the interaction between Resident #28 and LPN #431. STNA #420 reported she heard LPN #431 say, Please stop hitting staff and Resident #28 laughing. She heard a thud and turned to see LPN #431 use her forearm to pin Resident #28 against the wall and her other hand was on Resident #28's throat. STNA #420 reported she saw STNA #422 and other staff separate them. Resident #28 was crying and screaming. STNA #420 reported no prior concerns with LPN #431's interactions with residents. Review of the Witness Statements from the 12/29/22 SRI investigation revealed STNA #422 stated she rounded the corner because she heard LPN #431 yelling. Resident #28 was observed grabbing the narcotic book. LPN #431 told Resident #28 No and slapped her hand away. Resident #28 then reached toward (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 20 of 24 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 01/18/2023 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LPN #431's face. LPN #431 then choked Resident #28 with one hand and used her other arm to push Resident #28 against the wall. STNA #422 reported other staff heard the thud and the yelling and ran toward them. LPN #431 then dropped her hand from Resident #28's neck but continued to pin Resident #28 against the wall. Review of the email correspondence between the Administrator and the Corporate Office revealed on 01/03/23 the Administrator requested approval for termination of LPN #431. The email request stated during the SRI investigation two employees stated they saw LPN #431's hand on Resident #28's neck. The Administrator stated she and the Director of Nursing did not feel comfortable keeping LPN #431 employed. Interview on 01/09/22 at 7:23 A.M. with the Administrator verified the allegation of staff to resident abuse between LPN #431 and Resident #28 occurred on 12/29/22. The Administrator reported at the time of the investigation there was only one witness to LPN #431 holding Resident #28 to the wall with her hand on her neck. The SRI was unsubstantiated based on LPN #431 denying the allegation and only having one witness. The Administrator reported LPN #431 has not been back in the facility. Follow up interview on 01/09/23 at 8:07 A.M. with the Administrator revealed she reviewed the witness statements and verified there were two STNAs who witnessed LPN #431 pinning Resident #28 to the wall with her right forearm and having her left hand on Resident #28's neck. The Administrator verified the SRI should have been substantiated based on there being two witnessed to the interaction between LPN #431 and Resident #28. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 21 of 24 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 01/18/2023 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 AMENDED 02/14/23 Residents Affected - Few Based on observation, staff interview and review of the facility policy, the facility failed to ensure infection control practices were adhered to during a dressing change. This affected one (#8) of one resident observed during a dressing change. The facility census was 44. Findings include: Review of the medical record of Resident #8 revealed an admission date of 08/26/22. Diagnoses included malignant neoplasm of larynx, chronic obstructive pulmonary disease, peripheral vascular disease, depression, and anxiety disorder. The resident had a stage II pressure ulcer on the coccyx. Observation on 12/20/22 at 12:25 P.M. revealed Licensed Practical Nurse (LPN) #431 applied gloves and assisted Resident #8 to pull his pants and brief down, exposing his buttocks. LPN #431 removed a small (2 inch by 2 inch) boarded dressing from Resident #8's coccyx. The dressing had a scant amount of reddish drainage noted. The wound was observed to have no depth and appeared to measure approximately 0.5 centimeters (cm) in length and 0.2 cm in width. LPN #431 did not remove her gloves and perform hand hygiene. She then cleansed the wound with wound wash, applied a small amount of silver hydrogel soaked 2 inch by 2 inch single gauze to the wound, and covered it with a bordered gauze. Interview immediately following the procedure with LPN #431 provided verification she had not changed her gloves after removing the old dressing and prior to cleaning the wound or applying the new dressing. Review of the facility policy titled General Wound Care, dated 02/10/18, revealed remove the old dressing and place in an appropriate container, remove gloves and wash hands. Apply clean gloves and cleanse the wound from center outward. Remove gloves , wash hands and apply clean gloves and apply the dressing as ordered. This deficiency represents non-compliance investigated under Master Complaint Number OH00138604 and Complaint Number OH00136193. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 22 of 24 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 01/18/2023 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 0881 Implement a program that monitors antibiotic use. 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, staff interview, review of the infection surveillance log, and review of facility policy, the facility failed to ensure residents receiving an ongoing prophylactic antibiotic had a reason for continued use. This affected one (Resident #294) of six residents reviewed for unnecessary medications. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #294's medical record revealed an admission date of 12/08/22 and a discharge date of 12/26/22. Diagnoses included right arm fracture subsequent encounter with delayed healing, osteoarthritis, anxiety disorder, and depression. Review of Resident #294's Minimum Data Set (MDS) assessment, dated 12/15/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #294 was cognitively intact. Resident #294 had no infections at the time of the review. Review of Resident #294's Care Plan revised 12/20/22 revealed supports and interventions for antibiotic therapy for an infection. The infection was not specified. Review of Resident #294's progress notes revealed Resident #294 was admitted to the facility on [DATE]. No indications of Resident #294 having an infection or chronic history of infection were found. Review of Resident #294's admission Medication List revealed on 12/08/22, Resident #294 was admitted with an order for doxycycline monohydrate 50 milligrams (mg) two times a day. A reason for the antibiotic was not listed. In addition, no end date was provided. Review of Resident #294's physician orders revealed an order dated 12/08/22 and reordered 12/17/22 for doxycycline 50 milligrams (mg) give one capsule every morning and at bedtime for infection. The infection was not specified nor was the duration of use. Review of Resident #294's Skilled Nursing Assessments from 12/09/22, 12/11/22, 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/19/22, 12/21/22, 12/23/22, 12/24/22 and 12/25/22 revealed Resident #294 had no infectious disease concerns. Review of the facility's Infection Control Surveillance log for the last three months revealed Resident #294 was on the the log on 12/08/22 for prophylactic antibiotic use, doxycycline monohydrate 50 mg. No corresponding diagnosis was found. Interview on 01/03/23 at 8:32 A.M. with Infection Preventionist (Registered Nurse #447) and Regional Director of Clinical Operations Registered Nurse (RDCORN) #503 verified Resident #294 was the only resident in the facility in the last quarter who was on prophylactic antibiotics. It was reported Resident #294 was listed on the surveillance log for December 2022. Interview on 01/03/23 at 11:46 A.M. with RDCORN #503 verified the facility did not have a diagnosis for Resident #294's use of prophylactic antibiotics while she was in the facility from 12/08/22 through 12/26/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365495 If continuation sheet Page 23 of 24 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 01/18/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 01/03/23 RDCORN #503 provided documentation dated 05/23/22 from the Specialty Eye Clinic indicating Resident #294 was on doxycycline monohydrate 50 mg once a day for keratoconjunctivitis sicca. No start date or end date were provided and the diagnosis information was not received by the facility until 01/03/23. Review of the facility policy titled Antibiotic Stewardship Overview, revised 03/11/22, revealed the facility was to track how and why antibiotics were prescribed, review antibiotic starts to determine the clinical assessment, prescription, and documentation and antibiotic selection were in accordance with policy and procedures. Event ID: Facility ID: 365495 If continuation sheet Page 24 of 24