Health inspection·May 25, 2023

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated he left the facility out his window, walked to the gas station (roughly 0.3 miles and a six minute walk from the facility) from the facility and called the police the other night. RN #40 noted the window screen was removed from the window when he was escorted back to his room the night of 05/12/23. RN #40 assured the family member Resident #1 did not leave the facility the evening of 05/12/23. Review of the facility Self Reported Incident (SRI) dated 05/17/23, revealed on 05/16/23, Resident #1's family reported Resident #1 went out his window to the gas station and had a still photo of the gas station security camera showing Resident #1 wearing a large brimmed hat. The SRI did not include the date or time of the still photo in the investigation. Resident #1 was interviewed and stated he left the facility to report a rape involving no specific people to the sheriff. The resident was assessed with no injuries. The facility completed wellness checks and interviews with three female residents Resident #1 usually associated with in the facility which all revealed no injuries or concerns. On 05/17/23, the police were called regarding the rape report and spoke to Resident #1 as well as Resident #3 however the police did not file a report. The nurses notes were included in the investigation but there were no staff statements regarding the elopement. The investigation determined neglect was unsubstantiated. Interview with Licensed Practical Nurse (LPN) #5 on 05/24/23 at 11:35 A.M. verified there was no mention of the date or time of the still photo from the gas station in the SRI dated 05/17/23. LPN #5 verified there were no staff statements regarding the elopement and there were only nurses notes included in the facility investigation of Resident #1's elopement and possible neglect. LPN #5 verified the facility elopement investigation was not initiated until the family provided the still photo of Resident #1 at the gas station despite the family stating on 05/14/23 that Resident #1 indicated he had left the facility through the window and walked to the gas station. She verified it was unknown how long Resident #1 was outside of the facility on 05/12/23. Interview with Resident #1 on 05/24/23 at 12:40 P.M. revealed he left out of the window in order to talk to the Sheriff, then came back to the facility through the window. The resident stated he was a machinist and could fix or get out of anything. Interview with RN #40 on 05/24/23 at 3:05 P.M. verified on 05/12/23 around 7:20 P.M. the gate alarm sounded and she thought Resident #1 was attempting to leave the courtyard gate and had wet shoulders due to the rain. RN #40 indicated Resident #1 was agitated and was on the wrong hall. RN #40 indicated when she redirected him back to his room after the alarm sounded, she noticed the screen to his window was out of place. RN #40 verified she did not investigate the missing screen from the window. Phone interview with Resident #1's sister in law on 05/24/23 at 4:05 P.M. verified the still photo of Resident #1 at the gas station was from 05/12/23 at 5:18 P.M. She stated Resident #1 had a long history of making false allegations against his former wives and love interests when he saw them near another man. Review of the policy titled Investigation of Abuse, dated 12/2022, revealed the facility thoroughly and timely investigated all allegations or suspicions of abuse and neglect. Statements from witnesses were reviewed as part of the investigation. The policy further revealed neglect included a lack of supervision or care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366360 If continuation sheet Page 2 of 4 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 366360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Concord, The 119 West High Street Frankfort, OH 45628 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, review of a self reported incident, staff interview, resident and family interview, and policy review, the facility failed to ensure residents were adequately supervised to prevent elopement. This affected one (Resident #1) out of three residents reviewed for elopement. The census was 29. Findings include: Clinical record review revealed Resident #1 was admitted on [DATE] with diagnoses including dementia, traumatic subdural hemorrhage and psychosis. Review of the Minimum Data Set (MDS) assessment, dated 04/18/23, revealed Resident #1 had moderately impaired cognition, ambulated and used the toilet independently, and required the limited assistance of one staff for dressing, hygiene and bathing. Review of an Elopement Evaluation, dated 04/07/23, revealed Resident #1 did not have a history of elopement or elopement attempt and did not express a desire to leave; however, the resident wandered about the facility. The evaluation indicated Resident #1 was at risk for wandering/elopement. Review of the care plan, dated 05/16/23, revealed there were no interventions to address Resident #1's wandering/elopement risk prior to Resident #1's elopement on 05/12/23. Review of the progress note, dated 05/12/23 at 4:53 P.M., revealed Resident #1 was outside with the activity director and female peers. He was agitated and was making delusional comments regarding female peers and a male staff member. The staff attempted to redirect him without success and his agitation increased. He sat with his female peers for the evening meal in the dining area. Review of the progress note on 05/12/23 at 7:42 P.M. revealed Registered Nurse (RN) #40 responded to the alarm sounding, and the outside courtyard gate was open and Resident #1 was entering a hall where he did not belong and stated he had paperwork the girls needed. The resident became agitated and was redirected to his room. The progress note on 05/14/23 at 5:57 P.M. revealed Resident #1's family reported Resident #1 stated he left the facility out his window, walked to the gas station (roughly 0.3 miles and a six minute walk from the facility) from the facility and called the police the other night. RN #40 noted the window screen was removed from the window when he was escorted back to his room the night of 05/12/23. RN #40 assured the family member Resident #1 did not leave the facility the evening of 05/12/23. Review of a Self Reported Incident (SRI) revealed on 05/16/23, Resident #1's family reported Resident #1 went out his window to the gas station and Resident #1's family had a still photo of the gas station security camera showing Resident #1 wearing a large brimmed hat. There was no mention in the SRI of the date or time of the still photo. Resident #1 was interviewed and stated he left the facility to report a rape, involving no specific people, to the sheriff. Resident #1 was assessed with no injuries. Wellness checks and interviews with the three female peers Resident #1 usually associated with in the facility revealed no injuries or concerns. The nurses notes were included in the SRI but there were no staff statements regarding the elopement. The SRI determined neglect was unsubstantiated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366360 If continuation sheet Page 3 of 4 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 366360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vineyards at Concord, The 119 West High Street Frankfort, OH 45628 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 Interview with Licensed Practical Nurse (LPN) #5 on 05/24/23 at 11:35 A.M. revealed it was unknown how long Resident #1 was outside of the facility on 05/12/23. Interview with Resident #1 on 05/24/23 at 12:40 P.M. revealed he left out of the window of the facility in order to talk to the Sheriff, then came back thru the window. The resident stated he was a machinist and can fix or get out of anything. Interview with RN #40 on 05/24/23 at 3:05 P.M. verified on 05/12/23 around 7:20 P.M. the gate alarm sounded and she thought Resident #1 was attempting to leave the courtyard gate and had wet shoulders due to the rain. RN #40 indicated Resident #1 was agitated and was on the wrong hall. RN #40 indicated when she redirected him back to his room after the alarm sounded, she noticed the screen to his window was out of place. RN #40 verified she did not investigate the missing screen from the window. Phone interview with Resident #1's sister in law on 05/24/23 at 4:05 P.M. verified the still photo of Resident #1 at the gas station was from 05/12/23 at 5:18 P.M. She stated Resident #1 had a long history of making false allegations against his former wives and love interests when he saw them near another man. Review of the policy titled Wandering Residents dated 02/2019 revealed the facility shall take all reasonable measures to prevent elopement and assure resident safety from elopement. Nursing shall assess all residents for potential wandering within the first twenty-four hours of admission, with any pertinent significant change, after any new elopement attempts and as needed. Appropriate measures shall be put in place immediately after identifying a resident with moderate to high risk for wandering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366360 If continuation sheet Page 4 of 4