Inspection·September 12, 2019

F 0657 times with transfers. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #5's medical records revealed an admission date to the facility on [DATE] with diagnoses including unspecified severe protein-calorie malnutrition, anorexia, dysphagia following non-traumatic intracerebral hemorrhage, hemiplegia, and hemiparesis. Residents Affected - Few Review of Resident #5's physician's order dated 12/05/18 revealed to change the feeding tube every six months and as needed. The order dated 04/30/19 revealed to provide 250 milliliters(ml) of free water through the feeding tube before and after meals and at bedtime, and to hold tube feedings if residuals (amount of contents left in the stomach) were greater than 60 ml before meals and at bedtime. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #5 was moderately cognitively impaired. Review of Resident #5's care plan dated 06/28/19 revealed the resident had a feeding tube and was at risk for skin breakdown with interventions including to apply moisture barrier cream, change tube every six months, and flush with 30 ml of cola to maintain patency. Review of Resident #5's physician's order dated 07/18/19 revealed an order to flush feeding tube with 30 ml of cola as needed to maintain patency. Review of Resident #5's nursing progress notes dated 08/29/19 at 6:31 A.M., and 09/06/19 at 3:28 A.M., revealed the feeding tube was cleaned with a brush Interview with Resident #5 on 09/09/19 4:15 P.M. revealed concern there was a black build up in the tubing and the family had informed the facility previously of their concern. Observation of Resident #5's feeding tube on 09/09/19 4:15 P.M. revealed a black substance throughout the tubing. Interview with the Director of Nursing (DON) on 09/09/19 at 4:30 P.M. revealed Resident #5's family previously complained about the tubing in June and they changed the tube at that time. The DON stated the substance in the tubing was stains from medications such as the multivitamins going through the tube and that it was common for the tubing to stain. The DON further confirmed the tube was cleaned with a brush when the build up in the tubing was present and used cola to keep the tubing patent (flowing without difficulty). Interview with the DON on 09/10/19 at 4:00 P.M., verified there was not an intervention on Resident #5's care plan that addressed the cleaning of the feeding tube with a brush or the tube discoloration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 2 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide continuity of care when they did not transcribe three new pain medication orders for a resident following an emergency room visit. This affected one resident (Resident #32) of four residents reviewed for pain . The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 09/12/14 with diagnoses including dementia, anxiety, depression, insomnia, and right leg above knee amputee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had moderate cognitive deficits, received routine pain medication, and had no pain. Review of September 2019 physician orders and medication administration record revealed he received Norco two times a day for chronic pain and gabapentin three times a day for pain. There were no other pain medications. Review of daily pain assessments for September 2019 revealed pain was assessed from a score of three to seven ( based on pain scale of 0-10 with ten being the highest level of pain). Review of change in condition note dated 09/07/19 revealed Resident #32 sustained a fall with laceration to the bridge of his nose and abrasions to the right side of his face. The resident was transferred to the emergency room. Review of the emergency room disposition summary dated 09/07/19 revealed Resident #32 presented with complaints of fall injury with laceration to the nose and new orders for flexeril every eight hours as needed , motrin as needed, and ultram every six hours as needed for seven days. Review of the medical record was silent that any of these orders were transcribed upon return and medications were not ordered. Review of Resident #32's care plan revealed he was at risk for pain due to arthritis and pain was relieved by pain medication, rest and position changes. He had chronic pain and pain was worse in the evenings and with weather changes. Observation was conducted on 09/09/19 at 11:02 A.M. with Resident #32 and he was sitting up in wheel chair and had bruising to under his bilateral eyes and across the bridge of his nose. Interview was conducted on 09/10/19 at 9:16 A.M., with Resident #32 and he stated he had a fall on 09/07/19 and he went to the hospital. He stated nothing was broken and that his arms and back was sore and his nose hit the floor at time of fall. Observation and interview was conducted on 09/11/19 at 9:21 A.M., with Resident #32 and he was propelling himself in the hallway in a wheel chair. He stated he was a little sore but felt much better today and denied any pain just soreness. Interview was conducted on 09/11/19 at 9:33 A.M., with the Director of Nursing (DON) and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 3 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm verified the residents orders were not transcribed from the emergency room and were not ordered for Resident #32 due to they did not receive them from the hospital or any report from the hospital upon return and did not read them until she requested them on 09/10/19 after the surveyor had asked for the emergency room report. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 4 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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** 2. Review of Resident #32's medical record revealed an admission date of 09/12/14 with diagnoses including dementia, anxiety, depression, insomnia, and right leg above knee amputee. Review of physical therapy evaluation dated 07/16/19 revealed Resident #32 required the assistance of two staff members for transfers without falling. Review of physical therapy note dated 08/13/19 revealed they recommended two-person assistance for transfers and positioning for safety. Review of Resident #32's care plan revealed the resident was at high risk for falls related to a right above the knee amputation with balance issues, muscle weakness, and dementia. Interventions dated 10/08/18 revealed to utilize two staff assistance when applying the prosthetic leg, with transfers, ambulation, etc. Review of the quarterly MDS assessment dated [DATE] revealed he had moderate cognitive deficits and received extensive assistance of two staff for transfers. Review of change in condition note dated 09/07/19 revealed an aide alerted the nurse that Resident #32 fell to the floor during a transfer to a wheelchair. He was face down next to the bed with a moderate amount of blood pooled under his face when the nurse entered the room. Resident #32 stated he fell when the wheelchair moved, and his face hit the floor. The aide stated during the transfer from the bed to the wheel chair, Resident #32 leaned toward the glider in the room. The wheelchair moved to one side which caused the transfer to be unstable and Resident #32 fell face forward onto the floor. Resident #32 had a laceration to the bridge of his nose and abrasions to the right side of his face and was sent to the hospital. Interventions added included to check the wheel chair brakes for proper function. Review of the emergency room report dated 09/07/19 revealed Resident #32 presented with complaints of a fall injury with laceration to the nose. Wound care was provided with steri-strip application and a Computed Tomography (CT) scan which was negative for any injury. Observation was conducted of Resident #32 on 09/09/19 at 11:02 A.M. and noted he was sitting in the dining room in a wheel chair. The resident had bruising under both eyes and across the bridge of the nose. Interview was conducted on 09/10/19 at 9:16 A.M., with Resident #32. He stated the aide did not tighten up the lock on the wheel chair, he started to get into it, it pushed away, and he fell. He stated he was sent to hospital and nothing was broken. Interview was conducted on 09/11/19 at 7:05 A.M., with State Tested Nursing Assistant (STNA) #158. STNA #158 verified she was the aide that was transferring Resident #32 when he fell. She verified she was the only staff member present and she was not sure what his care plan stated as to whether he was a two person assist. She stated she pulled the wheel chair up next to the bed and locked the brakes. When she stood him up, he put out his hand onto the glider next to his bed and he lost his balance. STNA #158 stated she tried to catch him, but he went down. Interview was conducted on 09/11/19 at 7:24 A.M., with the DON verifying Resident #32's care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 5 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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 intervention included the use of two-person assistance from a fall he had back in October of 2018. She stated his level of assistance with transfers varied due to his mental capacity and that some days were better than others. Interview was conducted on 09/11/19 at 9:21 A.M., with Resident #32 and he stated he usually gets transferred per two staff and occasionally one staff will do the transfer. He stated staff used a mechanical lift to get him up yesterday. Review of the facility policy titled Restraint Policy dated 11/02/16 revealed goals of a restraint are to maintain a resident's independence and highest level of physical and psychosocial function. The restraint policy was the policy provided by the facility for falls during the survey. Based on medical record review, hospital record review, observation, staff interview and facility policy review, the facility failed to ensure Resident #33's fall interventions were implemented to prevent falls in accordance with the resident's fall risk care plan. This resulted in actual harm when Resident #33's bilateral side rails were not in place and the resident experienced a fall resulting in a laceration to the head and bruising. The resident was subsequently sent to the hospital and required staples. In addition, the facility failed to ensure staff implemented a second resident's (Resident #32) fall interventions in accordance with the care plan. This affected two (Resident #32 and Resident #33) of four residents reviewed for falls. The facility census was 89. Findings include: 1. Review Resident #33's medical record revealed an admission date of 12/13/17 with diagnoses including unspecified pain, unilateral primary osteoarthritis to the left knee, muscle weakness, difficulty in walking, and cerebral infarction due to embolism of unspecified cerebral artery (stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact and had one fall since admission. The MDS further revealed the resident required supervision and one-person assistance with mobility, transferring, dressing and hygiene. The resident utilized a walker for ambulating. Review of Resident #33's progress note and fall investigation dated 08/19/19 revealed the resident rolled out of bed and was found sitting up at the bedside. Resident #33 got herself off the floor. A new intervention was added to encourage the use of a pillow to define bed perimeters and to utilize 1/2 side rails on both sides on the bed for safe independent bed mobility. Review of Resident #33's physicians order dated 08/19/19 revealed an order for 1/2 side rails on both sides of the bed to encourage safe independent bed mobility. Review of Resident #33's care plan dated 08/19/19 revealed the resident was at risk for falls and an intervention was added to utilize half side rails for independent bed mobility. Review of Resident #33's progress note dated 08/24/19 revealed an aide notified the nurse Resident #33 was found on the floor with blood observed on her as well as on the floor. The resident stated she fell out of the bed. The resident had fallen within the last week. Review of Resident #33's fall investigation dated 08/24/19 at 10:50 P.M., revealed the resident was on the floor and was bleeding from her head. She was sent to the hospital. Further review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 6 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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 fall investigation revealed the location of the injury was at the back of the head and the resident was alert and oriented. Level of Harm - Actual harm Residents Affected - Few Review of Resident #33's hospital documentation dated 08/24/19 at 11:10 P.M., revealed the resident was transferred from the nursing home due to a head injury. The laceration was a 2.5 centimeters (cm) subcutaneous laceration to the left temporal area and was closed with staples. The hospital documentation revealed the resident had a moderate left frontal scalp hematoma and probable mild ecchymosis in the left posterior parietal scalp. Further review of Resident #33's nursing progress note dated 08/25/19 at 1:30 A.M., revealed the resident arrived back to the facility and had three staples in the back of her head. Nursing progress note dated 08/30/19 revealed bruising was noted to several areas of the resident's body due to fall on 08/24/19. Observation of Resident #33 on 09/10/19 at 9:48 A.M. revealed the resident had a large bruise on her face which started on her forehead and ran down to the middle of her chest. Interview with Resident #33 on 09/10/19 at 9:48 A.M. revealed she had fallen onto the floor two times in two weeks while turning over in bed. Resident #33 stated the facility was supposed to install bed rails on her bed after she fell out of the bed the first time, but they were not put in place until after the second fall. Interview with the Director of Nursing (DON) on 09/11/19 at 12:33 P.M., confirmed the bed rails for Resident #33 were ordered on 08/19/19 but were not put in place until 08/25/19 following the second fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 7 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a physicians order was in place for an indwelling urinary catheter (foley) for Resident #85. This affected one (Resident #85) of three residents with catheters in the facility. The facility census was 89. Findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses including a stage four pressure area to the sacral region, Alzheimer's disease, aphasia, dysphasia, delusional disorders, and adult failure to thrive. Review of the physician orders upon admission revealed Resident #85 did not have an order for a Foley catheter. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was severely cognitively impaired. Her functional status was listed as one to two-person extensive assistance for all activities of daily living except locomotion on and off the unit for which she was a total assist. Review of the care plan dated 08/30/19 revealed a plan was in place for Resident #85 with a 16 French Foley catheter in place related to a stage four pressure ulcer to the sacrum. This was to promote healing and decrease moisture to the skin due to incontinence. Interview with the Director of Nursing (DON) on 09/09/19 at 11:00 A.M., confirmed Resident #85 did not have an order to have a Foley catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 8 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview and facility policy, the facility failed to date and label oxygen tubing for two (Resident #29 and Resident #65) of 28 residents on oxygen therapy. The facility census was 89. Residents Affected - Few Findings include: 1. Review of Resident #29's medical record revealed an admission date of 05/28/19 with diagnoses including diffuse traumatic brain injury with loss of consciousness, occlusion and stenosis of right carotid artery, hypoxemia, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had long and short term memory deficits. Review of Resident #29's physician order dated 09/06/19 revealed an order for oxygen two to four liters per minute per nasal canal and order dated 09/08/19 revealed to change oxygen tubing every Sunday. Review of Resident #29's progress note dated 09/06/19 revealed an oxygen saturation level of 44-45% on room air and oxygen was applied to increase oxygenation level. Observation of Resident #29's oxygen concentrator on 09/09/19 at 9:42 A.M. revealed nasal cannula tubing attached to the concentration had no date or initials on the tubing. Interview with Licensed Practical Nurse (LPN) #92 on 09/09/19 at 9:44 A.M. confirmed the nasal cannula tubing was not dated and Resident #29 used the oxygen when needed. Review of the facility policy titled Disposable Supply Changes dated 05/14/15 revealed disposable supplies needed to be dated when changed and oxygen cannula are changed weekly. 2. Review of Resident #65's medical record revealed an admission date of 06/03/19 with diagnoses including insomnia, failure to thrive, and unspecified dementia without behavior disturbance. Review of Resident #65's progress note dated 07/20/19 revealed oxygen was increased to four liters for an oxygen saturation level of 92% to 93% . Review of the progress note dated 07/25/19 revealed resident was on oxygen therapy and had oxygen saturation level of 94%. Review of Resident #65's MDS dated [DATE] revealed the resident was cognitively intact and on oxygen therapy. Review of Resident #65's physician order dated 08/21/19 revealed an order for oxygen as needed to keep oxygen saturation levels above 94%. Observation of Resident #65's oxygen concentrator on 09/09/19 at 9:05 A.M. revealed tubing was attached to the concentrator and was undated. Interview with Resident #65 on 09/09/19 at 9:05 A.M., revealed resident used oxygen therapy for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 9 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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 0695 past couple days as she had a cough. Level of Harm - Minimal harm or potential for actual harm Interview with Registered Nurse (RN) #110 on 09/09/19 at 9:15 A.M. confirmed Resident #65's oxygen tube was undated and it should be dated. RN #110 further stated oxygen tubing was to be changed once a week and was to be dated at the time it was changed. Residents Affected - Few Review of the facility policy titled Disposable Supply Changes dated 05/14/15 revealed disposable supplies need to be dated when changed and oxygen cannulas are changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 10 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to serve and distribute food under sanitary conditions during dining observation. This had the potential to affect 25 (Resident #3, #10, #11, #13, #20, #24, #28, #32, #35, #38, #40, #43, #45, #46, #48, #49, #50, #53, #56, #57, #61, #67, #71, #74, and #77) residents residing on the A wing. The facility census was 89. Findings include: Observation was conducted on 09/09/19 at 11:16 A.M., of the dining room on A wing. [NAME] #136 was preparing trays to serve in the dining room and she was touching hamburger buns with her bare ungloved hands and was observed pulling up her pants and wiping her hands on her uniform then continued to touch the buns without washing her hands and/or putting on gloves. [NAME] #136 would get the bun out of the package with bare hands, opened up the bun, placed philly steak on the bun then would touch the top bun with her bare hands. [NAME] #136 would then pat the sandwich down touching the top bun with her bare hands. She continued this process with all trays made. Observation was conducted on 09/09/19 at 11:25 A.M., of [NAME] #136 make the hall trays for A wing and she pulled up her pants from the back waistline then touched plates, took out buns out of the package and proceeded to make sandwiches with bare ungloved and unwashed hands. Observation was conducted on 09/09/19 at 11:30 A.M., of [NAME] #136 open up the door off the serving area of A wing by punching in door code, opened up the door with her hands, get two cartons of milk out, and returned to the serving area without washing her hands. [NAME] #136 then continued to make trays by touching buns with her bare hands. Interview was conducted on 09/09/19 at 11:53 A.M., with [NAME] #136 verified she did not wash her hands and did not utilize gloves when touching buns and other surfaces. There were 25 residents (Resident #3, #10, #11, #13, #20, #24, #28, #32, #35, #38, #40, #43, #45, #46, #48, #49, #50, #53, #56, #57, #61, #67, #71, #74, and #77) residing on the A wing. Review of facilities Hand Hygiene Procedure Policy dated March 2009 revealed hand hygiene was essential to reducing over all infections. It was the policy of the facility that all handwashing was considered the number one defense against preventing the spread of infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 11 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy review, the facility failed to cleanse a blood glucometer machine per manufacture instructions. This had the potential to affect 23 (Resident #2, #8, #9, #13, #20, #30, #31, #32, #39, #42, #46, #54, #58, #60, #66, #67, #69, #83, #88, #140, #141, #142, and #339) residents who require blood glucose monitoring, and failed to ensure Resident #70 who was in contact isolation, had a sign posted on the door to alert staff and visitors to see the nurse for necessary precautions to take before entering the room. This affected one of one residents reviewed under infection precautions area. The facility census was 89. Residents Affected - Some Findings include: 1. Observation of Registered Nurse (RN) #110 on 09/10/19 at 4:22 P.M. revealed the nurse completed a blood glucose fingerstick for Resident #81. RN #110 then cleaned the glucometer with wipes from the top drawer of the cart. Review of the manufactures instructions for the glucometer cleaning Cleaning and Disinfecting your Meter (undated) revealed cleaning and disinfecting the meter was very important to prevent infectious diseases and ensure germs were destroyed on the meter. There were products listed which were validated to disinfect the meter and lancing device. The wipes used by RN #110 were not listed in the manufactures instructions for validated use with the glucometer. Interview with RN #110 on 09/10/19 at 4:23 P.M., confirmed the facility utilized wipes that do not contain bleach to clean the glucometer and they were not the correct type of wipes, however, the wipes she used were the only ones available in the facility carts. RN #110 went to the supply room to find the correct wipes but was unable to locate them. Interview with the DON on 09/10/19 at 5:50 P.M. verified staff are to use the manufacturers instructions for glucometer cleaning and they do not have a separate policy. The DON also verified the staff were using cleansing wipes which were not validated on the manufactures instructions for usage. The facility identified 23 (Resident #2, #8, #9, #13, #20, #30, #31, #32, #39, #42, #46, #54, #58, #60, #66, #67, #69, #83, #88, #140, #141, #142, and #339) residents who require blood glucose monitoring. 2. Review of Resident #70's medical record revealed an admission date of 07/27/19 with diagnoses including pressure ulcer of sacral region (stage four), cellulitis of the left lower limb, need for assistance with personal care, unspecified dementia without behavioral disturbance, paraplegia and major depressive disorder. Review of Resident #70's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance from two people for mobility, transfer, dressing, toileting and hygiene needs. Review of Resident #70's physician orders dated 09/06/19 revealed the resident was placed on contact precautions (procedures to minimize the transmission of infections through direct and indirect contact with an infected individual) and an order for the medication Clindamycin HCL (an antibiotic) 300 milligrams (mg) three times a day related to pressure ulcer of sacral region, stage four for 21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 12 of 13 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 365928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Court House Manor 555 North Glenn Ave Washington Court Hou, OH 43160 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 days. Level of Harm - Minimal harm or potential for actual harm Review of Resident #70's care plan dated 09/11/19 revealed the resident had an infection of the stage four sacral wound and was on contact precautions due to multiple strains of bacteria in the sacral wound with interventions to follow facility policy and procedures for listing, summarizing and reporting infections and maintain universal standard precautions when providing resident care. Residents Affected - Some Observation of Resident #70's room on 09/11/19 at 8:45 A.M. revealed a cart with personal protective equipment (gowns, gloves, and masks) sitting outside of Resident #70's room. There was no sign on the door or on the cart indicating instructions that staff and visitors should follow before entering the room. Interview with Registered Nurse (RN) #132 on 09/11/19 at 8:45 A.M., confirmed Resident #70 was on contact precautions due to her wound being infection. RN #132 stated Resident #70 had Methicillin-resistant staphylococcus aureus (MRSA) in the wound and was recently put under contact precautions. RN #132 verified there was not a sign on the door indicating instructions visitors and staff should take upon entering the door. MRSA was a bacteria that was resistant to commonly used antibiotics. Interview with the Director of Nursing (DON) on 09/11/19 at 9:35 A.M., verified Resident #70 was on contact precautions and was not on the original matrix provided. The DON was unable to say why there would not be a sign on Resident #70's door. Review of the facility policy titled Standard Precautions dated 03/2009 revealed contact precautions may be considered for MRSA and precautions should be maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365928 If continuation sheet Page 13 of 13