Inspection·July 7, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few members on 05/22/22 and 05/23/22 with no staff members having knowledge of Resident #38 being involved in any incidents; however, staff members indicated Resident #38 was unsteady on her feet and running into walls on previous shifts, had shown increased aggression, lunging, hitting, kicking, biting, and spitting at staff but no definitive cause of Resident #38's bruise to her left eye was identified. The facility reviewed progress notes surrounding the finding of the bruise between 05/17/22 and 05/21/22 and found documentation of increased behaviors but no falls or incidents where Resident #38 injured her left eye. Review of SRI's between 06/17/21 and 06/30/22 revealed the facility did not submit any allegations of injuries of unknown origin during this time frame. Further review of the SRI's revealed the bruise to Resident #38's left eye was not submitted to the State Survey Agency with no SRI's submitted by the facility between 05/10/22 and 06/01/22. An interview was attempted with Resident #38 on 07/06/22 at 8:24 A.M., however, Resident #38 responded with very low, incoherent mumbled speech and was not able to answer any questions related to the bruise on her left eye discovered on 05/22/22. Interview on 07/07/22 at 1:11 P.M. with the Director of Nursing (DON) stated the facility investigated the bruise to Resident #38's left eye and did not discover any definitive causes. The DON stated written statements and progress notes were reviewed during the investigation and Resident #38 was documented to be experiencing a lot of behaviors and had a unsteady gait. The DON stated due to all of Resident #38's behaviors and unsteady gait she did not feel the bruise to her left eye was suspicious as her gait and behaviors would be likely causes of the bruise. The DON verified Resident #38 had no documented falls or an incidents around the time the bruise was discovered, and verified there was no SRI submitted since she felt the bruise was not suspicious. Review of the facility's undated abuse policy defined injury of unknown source as the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury, the number or injuries observed at one particular point in time, or the incidence of injuries over time. Incidents and allegations of injuries of unknown source must be reported to the Administrator or designee and they will notify the Ohio Department of Health (ODH) of injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. The facility will submit an online self-reported incident form in accordance with ODH's then-current instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366217 If continuation sheet Page 2 of 7 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 366217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Court 1925 E Fourth St Ottawa, OH 45875 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, medial record review, and resident and staff interview, the facility failed to develop a comprehensive care plan to include a resident's vagus nerve stimulator (VNS) used to treat seizures. This affected one (#29) of 15 residents reviewed for care plans. The facility census was 49. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/03/20 and a readmission date of 10/13/20. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke), epilepsy, mild intellectual disability, major depressive disorder, anxiety disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #29 was cognitively intact, required supervision for ADL's, had a seizure disorder. Review of the plan of care, initiated 10/26/20, revealed Resident #29 was at risk for adverse effects and/or side effects from anticonvulsant therapy and had a diagnosis of epilepsy. The care plan for Resident #29's contained no documentation regarding the use of a VNS - implanted device used to treat seizures. Observation on 07/05/22 at 12:35 P.M. of Resident #29 revealed the Resident #29 was wearing a black, watch size object on the right collar of her shirt. Interview of Resident #29 at the time of the observation revealed the resident had epilepsy and had a VNS to help control her seizures. Resident #29 verified the black, watch size object was the magnet used for the VNS. Resident #29 stated she had the VNS for a long time, was able to recognize auras prior to a seizure and was able to use the magnet to activate the VNS when needed. Interview on 07/06/22 at 7:57 A.M. of Licenses Practical Nurse (LPN) #406 verified Resident #29 had a VNS and carried her own magnet to activate the VNS when needed. LPN #406 stated Resident #29 was very familiar with her seizures and auras and was able to swipe the magnet over the VNS generator to prevent a seizure. Interview on 07/06/22 at 9:59 A.M. of the Director of Nursing (DON) verified Resident #29 had a VNS and it was not included in the resident's care plan. The DON stated Resident #29 admitted to the facility with the VNS and mostly managed it herself but stated it should definitely be care planned. Follow up interview on 07/06/22 at 1:14 P.M. of the DON revealed the facility did not have a policy related to care planning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366217 If continuation sheet Page 3 of 7 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 366217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Court 1925 E Fourth St Ottawa, OH 45875 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one resident (#40) of two residents reviewed for falls. The facility census was 49. Findings include: Review of Resident #40's medical record revealed an admission date of 07/21/03. Diagnoses included dementia with behavioral disturbance, muscle weakness, abnormalities of gait, schizoaffective disorder, pseudobulbar affect, and epilepsy. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating Resident #40 was severely cognitively impaired. Resident #40 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #40 displayed verbal behavioral symptoms directed toward others four to six days during the review period. Resident #40 had no falls since the last review. Review of Resident #40's care plan revised 04/12/21 revealed supports and interventions for risk for falls. Interventions for falls included anticipate Resident #40's needs, encourage use of call light, ensure Resident #40 was wearing appropriate footwear when ambulating or mobilizing in his wheelchair, evaluate for appropriate equipment and devices, and provide a safe environment. Review of Resident #40's Fall Risk assessment dated [DATE] revealed Resident #40 was at risk for falls. Review of Resident #40's State Tested Nursing Assistant Tasks revealed a task for dressing which stated Resident #40 was able to complete lower body dressing with stand by assistance, briefs with minimal assistance and shoes with set up. Resident #40 ranged from supervision to extensive assistance with dressing over the last 20 days. Observation on 07/05/22 at 9:28 A.M. of Resident #40 found him standing and walking in front of his wheelchair using it as a walker. Resident #40 was wearing regular white socks with no shoes. Attempted interview with Resident #40 found he was not able to be interviewed. Interview on 07/05/22 at 9:30 A.M. with Licensed Practical Nurse (LPN) #445 verified Resident #40 was pushing his wheelchair as a walker and it was not safe. LPN #445 asked Resident #40 to sit down in his wheelchair and the resident complied. Observation on 07/05/22 at 9:42 A.M. found Resident #40 standing using his wheelchair as a walker. Resident #40 continued to have regular socks on without grips and no shoes. Resident #40 was pushing his wheelchair around the hallways past staff and no redirection or interventions were provided. Resident #40's tennis shoes were observed to be in his room at the foot of his bed, positioned side by side. Observation on 07/05/22 at 4:38 P.M. found Resident #40 seated in his wheelchair propelling himself with his feet. Resident #40 continued to wear only white regular socks with no shoes. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366217 If continuation sheet Page 4 of 7 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 366217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Court 1925 E Fourth St Ottawa, OH 45875 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 #40's shoes were found to be in the same position at the foot of his bed. Level of Harm - Minimal harm or potential for actual harm Observation on 07/05/22 at 4:40 P.M. found Resident #40 standing and pushing his wheelchair like a walker. Resident #40 was not wearing shoes and had only regular white socks on without grips. Residents Affected - Few Observation on 07/05/22 at 4:44 P.M. with the Director of Nursing (DON) found her redirecting Resident #40 to sit in his wheelchair and not push it. Resident #40 laughed and complied. Coinciding interview with the DON verified Resident #40 was not supposed to be standing and pushing his wheelchair and verified he was not wearing proper shoes or non-skid socks. The DON stated she would help him get proper footwear on. Interview on 07/06/22 with State Tested Nursing Assistant (STNA) #416 revealed Resident #40 was able to put his shoes on, but required staff assistance with getting them positioned so he could put them on. Resident #40 was not able to safely reach them if they were on the floor. STNA #416 reported he was able to dress himself with specific directions and getting all of the item out and laid out for him. Review of the undated facility policy titled, Falls Policy and Procedures, revealed residents would be reviewed for fall risk and applicable interventions would be implemented in accordance with the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366217 If continuation sheet Page 5 of 7 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 366217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Court 1925 E Fourth St Ottawa, OH 45875 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 observations, resident and staff interview, review of the facility infection control log and review of the owner's manual for the chemical dishwasher, the facility failed to ensure dietary staff with skin conditions kept their arms properly covered and failed to ensure the chemical dishwashing machine maintained the appropriate level of chemicals for effective sanitation. This had the potential to affect all 49 residents residing in the facility. The facility census was 49. Findings include: 1. Observation on 07/05/22 at 8:51 A.M. of the kitchen found Dietary Staff (DS) #412 wearing a short sleeve black shirt. DS #412's arms were exposed and observed having flakey, white, scale like skin on both his right and left forearms. DS #412's right forearm was observed to have cracks with scabs and dried red areas between his elbow and his wrist as well as on the back of his right hand. DS #412 was observed preparing batter for pancakes and cooking pancakes on the stove. Interview on 07/05/22 at 9:33 A.M. with Resident #22 revealed the food was very good but the cook had some white stuff on his arms that wasn't good. Resident #22 did not elaborate as to what he meant by the cooks arms weren't good. Observation on 07/05/22 at 11:15 A.M. of the kitchen found DS #412 continued to work in the kitchen preparing food with white flakey skin on both arms and with cracked areas with dried blood on right forearm between his elbow and his wrist as well as the back of his right hand. DS #412 was observed preparing purees for the lunch meal. Interview on 07/05/22 at 11:34 A.M. with DS #412 revealed he had psoriasis and normally wore sleeves which covered his arms while he was working in the kitchen. DS #412 verified he was not wearing his sleeves, his psoriasis was cracked, and his arms were not covered while he was preparing food. 2. Observation on 07/05/22 at 8:48 A.M. of the kitchen found DS #408 running dishes through the dishwasher. Coinciding interview with DS #408 revealed the dishwasher was a chemical machine with sodium hypochlorite as the sanitizer and she did not have test strips to test if the chemicals were reaching proper levels. DS #408 stated it had been some time since they had test strips and she had no way of knowing the sanitation levels of the machine. Interview on 07/05/22 at 11:19 A.M. with DS #408 revealed DS #412 was able to find some test strips. Observation of the use of the test strips revealed the sanitation level was at 10 parts per million (PPM) and machine was supposed to run at 50 PPM. DS #408 verified the dishwasher was not reaching the proper level of sanitation for the sodium hypochlorite sanitizer. DS #408 reported they were supposed to be testing the chemical level every shift to make sure it was at the proper levels but they had not had test strips for some time so they were not completing testing and they were not keeping a log. Observation and interview on 07/05/22 at 11:21 A.M. with DS #412 found he ran the chemical level test again, found the sanitation level to be around 25 PPM, and verified the dishwasher was not reaching appropriate levels for sanitation. DS #412 reported it was not known how long the dishwasher had not been reaching the appropriate levels for sanitation as they had not had test strips available and a log was not being kept. DS #412 reported now they were aware of the issue they would put a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366217 If continuation sheet Page 6 of 7 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 366217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Court 1925 E Fourth St Ottawa, OH 45875 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 repair order in and would use the three sink system to wash dishes until it was repaired. The facility confirmed all 49 residents residing in the facility receive their meals from the kitchen. Review of the Infection Control Log from 11/01/21 through 07/05/22 revealed there have been no food borne illnesses at the facility. Residents Affected - Many Review of the Owners Manual for the American Dish Service Upright Dishwasher dated May 2008 revealed the chemical sanitizer used in the dishwasher was sodium hypochlorite and in the final rise should be 50 PPM to 100 PPM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366217 If continuation sheet Page 7 of 7