Health inspection·May 30, 2024

F 0553 the individual making the contact. 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: 366012 If continuation sheet Page 2 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to provide the resident council with responses and action regarding their concerns regarding activities. This affected five residents (Resident #3, #5, #20, #27 and #36) who regularly attend council meetings and had the potential to affect all residents. The facility census was 38. Residents Affected - Many Findings include: Review of the facility resident council meeting minutes from 11/22/23 to 05/14/24 revealed the residents had voiced the following concerns related to activities during resident council meetings: a. At the resident council meeting held 11/22/23 , residents voiced concerns regarding knowing when activities are held, and where activity calendars were placed in their rooms. Residents requested more physical activities and more variety of activities. Listed action taken included giving reminders throughout the day and adding more variety to the calendar. There was additionally a concern with bingo candy raised, with the action taken including AD #88 speaking to the administrator about bingo candy. The Administrator's recorded written response stated bingo treats and prizes were available for residents. b. At the resident council meeting held 12/26/23 , residents requested longer bingo games. Action taken included adding two more games to each bingo date, and increased bingo frequency to three times per week. c. At the resident council meeting held 01/16/24, residents voiced concerns that there were not enough games, games needed to be an hour long, and that activities were short. Action to be taken listed a notation of bingo going well and speaking to the residents of trying other ways to play games. d. At the resident council meeting held 02/13/24, residents voiced concerns regarding wanting better games, with suggestions including Uno, Yahtzee, and pong. Residents additionally requested more card games, board games, and bible studies. More cooking classes were additionally requested as the residents enjoyed making chocolate covered strawberries. e. At the resident council meeting held 04/16/24, residents voiced concerns regarding wanting more outdoor activities since the weather was improving and requested music in the courtyard. Review of the facility activity calendar dated November 2023 revealed there were three to four activities per weekday, with the latest activity, sudoku games, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 3 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0565 on Sundays the activities listed was church services on the television in the lobby, with no listed time. Level of Harm - Minimal harm or potential for actual harm Review of the facility activity calendar dated December 2023 revealed there were three to four activities per weekday, with the latest activity, a holiday movie, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Residents Affected - Many Review of the facility activity calendar dated January 2024 revealed there were three to four activities scheduled per weekday, with the latest activity, bingo, timed for 2:30 P.M. on one day. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated February 2024 revealed three to four activities scheduled per weekday. There was one listed evening activity, a Valentine's Day dinner in the evening on 02/13/24. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time, except for a super bowl party held on 02/11/24 at 2:00 P.M. Review of the facility activity calendar dated April 2024 revealed three to four activities listed per weekday, with the latest activity, a movie, listed on one day at 4:00 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated May 2024 revealed no scheduled activities were listed for Mother's Day or Memorial Day. Three to four activities were scheduled per weekday, with the latest activity listed as 4:15 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. During the resident council interview on 05/29/24 at 9:40 A.M. with Residents #3, #5, #20, #27, and #36 revealed that their biggest concern was with activities. The residents stated that they needed more activities because there are none on the weekends or in the evenings. Resident #5 stated that they mentioned concerns with activities before to administration. Resident #5 stated that there used to be coloring books, games and different things but are not available anymore. During an interview on 05/29/24 at 2:46 P.M., Activities Director (AD) #88 stated she had been the Activity Director since October 2023. She worked at the facility full-time, from 8:00 A.M. to 4:30 P.M. Monday through Friday. Occasionally she would come to work on the weekend, but not consistently. AD #88 confirmed she was the only activity staff member who worked at the facility, and she was responsible for creating the monthly activity calendars. AD #88 stated she tried to accommodate resident preferences and requests, but the key word was try. She stated the residents want more games, but it is hard as she had never played the requested games and had to be taught by the residents. AD #88 confirmed there are no consistent, planned activities in the evening and on the weekends as those are times she is not scheduled to work. AD #88 stated she would like to eventually find volunteers to help facilitate some activities but currently there are no volunteers. AD #88 stated she had not heard concerns related to the timing of activities voiced by residents but when she does coordinate the occasional weekend activities the residents enjoy it immensely. AD #88 stated that she does not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 4 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0565 think that the radio was waterproof, so that music can be played outside. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 5 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and policy review, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the resident preferences and failed to ensure activities were scheduled on evenings and weekends. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Residents Affected - Many Findings include: Review of the Activity Participation Logs for March 2024, April 2024, and May 2024 revealed all residents had their own log for each month, on which residents' activity participation was logged. Residents were recorded as participating in activities, based on the date, and participation was logged as active, passive, or refusal to participate. The logs consistently were blank for Saturdays and Sundays, indicating no participation in activities. During an interview on 05/28/24 at 9:19 A.M., Resident #14 stated there used to be activities on the weekend but there are no longer. The resident stated he felt like he was in jail as there was nothing to do. During an interview on 05/28/24 at 9:26 A.M., Resident #21 stated there were no activities, as the activity director had left her position a few weeks prior. During an interview on 05/28/24 at 10:52 A.M., Resident #10 stated there were never any activities in the evenings or on the weekends. Resident #10 stated the activity director had left or was leaving her position, and the facility likely would no longer have any activities. Review of the activity calendar revealed a badminton activity. During an observation on 05/28/24 from 10:55 A.M. to 11:07 A.M., there was no badminton activity taking place. Eight residents were observed seated in the common area near the nurses' station, with seven of them sleeping. During an interview on 05/28/24 at 11:07 A.M., Resident #03 stated he had just returned to his room after visiting the common area by the nurse's station. He had attempted to go to the listed badminton activity but there was no one there. Resident #03 stated the activities frequently do not follow the calendar. Resident #03 voiced concern that there had been no activities on Memorial Day (05/27/24), nor did the facility have weekend activities. He checked his posted activity calendar in his room which listed additional activities of a cookout at 12:00 P.M. and cornhole games at 1:30 P.M. The resident stated yeah right about the facility holding a cookout. During an observation on 05/28/24 at 12:07 P.M., there was no cookout taking place. 19 residents were observed eating a normal lunch in the dining room. During an interview on 05/28/24 at 1:24 P.M., Resident #19 stated activities were great when they have them, but staff did not always follow the schedule. The resident stated there were not many participants and was not sure what would happen as Activity Director (AD) #88 was leaving her position. AD #88 was nearby and joined the conversation. Resident #19 asked AD #88 who would be taking over activities, and AD #88 responded that the facility was still trying to figure that out. AD #88 confirmed at that time she was the only activity staff member employed at the facility. During an observation on 05/29/24 at 8:39 A.M. eight residents seated in the common area near the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 6 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many nursing station. One resident was in a tilt in space wheelchair, facing away from the television. The television was on with a news program playing, with the television volume so low it was difficult to hear. During interview at the time of the observation, Resident #12 and Resident #24 stated they could not hear the television. During an interview on 05/29/24 at 8:41 A.M., State Tested Nursing Assistant (STNA) #84 verified the television was turned low, but she was unsure how to work the television. Resident #12, seated nearby, informed the staff member there were two remotes attached to the wall by Velcro next to the television, out of all the resident's reach. STNA #84 retrieved the remotes and raised the volume from the level of 22 to 48. During the resident council meeting survey task on 05/29/24 at 9:40 A.M., Residents #03, #05, #20, and #36 stated there were no activities in the evenings, nor on the weekends. Resident #05 stated there used to be coloring books, games, and different things to do which were no longer available. Resident #05 stated residents had voiced these concerns at prior facility-led resident council meetings and nothing was done. Review of the facility activity calendar dated November 2023 revealed there were three to four activities per weekday, with the latest activity, sudoku games, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated December 2023 revealed there were three to four activities per weekday, with the latest activity, a holiday movie, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated January 2024 revealed there were three to four activities scheduled per weekday, with the latest activity, bingo, timed for 2:30 P.M. on one day. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated February 2024 revealed three to four activities scheduled per weekday. There was one listed evening activity, a Valentine's Day dinner in the evening on 02/13/24. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time, except for a super bowl party held on 02/11/24 at 2:00 P.M. Review of the facility activity calendar dated April 2024 revealed three to four activities listed per weekday, with the latest activity, a movie, listed on one day at 4:00 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated May 2024 revealed no scheduled activities were listed for Mother's Day or Memorial Day. Three to four activities were scheduled per weekday, with the latest activity listed as 4:15 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 7 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0679 lobby, with no listed time. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/29/24 at 2:46 P.M., AD #88 stated she had been the Activity Director since October 2023. She worked at the facility full-time, from 8:00 A.M. to 4:30 P.M. Monday through Friday. Occasionally she would come to work on the weekend, but not consistently. AD #88 confirmed she was the only activity staff member who worked at the facility, and she was responsible for creating the monthly activity calendars. AD #88 stated she tried to accommodate resident preferences and requests, but the key word was try. She stated the residents want more games, but it is hard as she had never played the requested games and had to be taught by the residents. AD #88 confirmed there are no consistent, planned activities in the evening and on the weekends as those are times she is not scheduled to work. AD #88 stated she would like to eventually find volunteers to help facilitate some activities but currently there were no volunteers. AD #88 stated she had not heard concerns related to the timing of activities voiced by residents but when she does coordinate the occasional weekend activities the residents enjoy it immensely. AD #88 verified that the scheduled activities of badminton and a cookout on 05/28/24 did not occur as posted on the activity calendar as she had an urgent personal matter to attend to, and verified she did not post an activity schedule change anywhere but had told the aides she would reschedule it. AD #88 additionally verified the previous listed activity on 05/23/24 of gardening did not occur, and she was not beginning gardening until 05/30/24. Residents Affected - Many Review of the policy titled Activity Programs, revised August 2006, revealed activity programs designed to meet the needs of each resident are available daily. Activities are scheduled 7 days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the activity program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 8 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review, staff interview, and review of the facility activity director job description, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Residents Affected - Many Findings include: Review of Activity Director (AD) #88's personnel record revealed a hire date of 10/04/23. AD #88 signed the Activity Director job description on the date of hire, which listed primary functions and responsibilities of then position which included planning, scheduling, and implementing a program of individual and group activities based on the residents' schedule, plan and implement evening and weekend functions as necessary, and recruit, schedule and supervise assistants and volunteers, and maintain an activity attendance record for each resident. The section on Education/Experience, noted as to be completed by the facility, was blank. AD #88's personnel record contained no evidence of formal training in an activities or therapeutic recreation program or full-time experience in a therapeutic activities program. During an interview on 05/29/24 at 2:46 P.M., AD #88 confirmed she was not a certified activity director. AD #88 revealed she had previously worked part-time at another skilled nursing facility as an activities assistant for approximately two years. AD #88 stated in her prior role she worked two days per week in the activities department, on weekends, and sought new employment because of a lack of days and hours. AD #88 indicated she had discussions with the Administrator off and on about getting certified as an activity director but had not yet committed to completing nor was she enrolled in a program to become a certified activities professional. During an interview on 05/30/24 at 9:20 A.M., the Administrator verified he was aware AD #88 did not meet the minimum qualifications of an activities professional and had discussed the certification process with AD #88 on multiple occasions. The Administrator stated he believed AD #88 fell under the umbrella of a sister facility's former activity director who was certified. The Administrator stated he was aware of the regulatory requirements and would discuss with AD #88 a plan to get her certified or recruit a certified activity director to oversee the activities program. Review of the form titled Job Description and Performance Standards for the position of Activity Director, revised 01/07/10, revealed the purpose of this position is to develop and implement an activity program in compliance with requirements to meet residents' needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 9 of 10 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation, interview and record review, the facility failed to ensure proper ware washing and failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 38 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 38. Findings include: During a tour of the kitchen on 05/28/24 at 7:49 A.M., the reach-in freezer contained frozen fruit and waffles that were out of their original package and were not labeled or dated. In the dry storeroom, there was a can of baked beans and a can of sliced apples that were dented and were not separated from the other canned goods. Dietary Manager (DM) #55 verified observations on 05/28/24 at 8:10 A.M. DM #55 stated that he did not know that dented cans needed to be separated. During observation on 05/29/24 at 8:30 A.M., Dietary Aide (DA) #40 check for the chlorine concentration of the dish machine and it was not registering any sanitizer. The dish machine was repaired and on 05/29/24 at 9:50 A.M., registered 50 ppm of chlorine. Review of the facility policy dated 07/2014 titled, Food Receiving and Storage, revealed that food should be labeled and dated when removed from original package. Review of the facility policy dated 03/2010 titled, Dishwashing Machine Use, revealed that dishwashing machine chemical sanitizer concentration was 50-100 parts per million (ppm) for chlorine-based sanitizer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366012 If continuation sheet Page 10 of 10