Inspection·November 6, 2019

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/04/19 at 5:45 P.M., Social Service Coordinator (SSC) #106 confirmed the facility had not completed a concern form nor followed up or provided a rationale to the Resident Council regarding activities not occurring. Interview on 11/05/19 at 3:03 P.M. during the Resident Council Meeting, Resident #37 confirmed there was still a concern with activities not occurring as scheduled and that she had never received a response/rationale from the facility. Review of a facility policy, titled, Activity Program/Calendar Policy, dated November 2009, revealed the facility would provide activity programming to promote physical, cognitive, and/or emotional health, and that supports self-expression, exercise, socialization, lifestyle programs and leisure pursuits. Activities would be offered every day, for a minimum of six hours per day. 2. Review of Resident #15's medical record revealed she was admitted to the facility 10/08/18. Review of Resident #15's MDS dated [DATE] revealed she was cognitively intact. Review of an undated appointment list for Resident #15 revealed appointments 06/10/19 at 10:00 A.M. and 08/26/19 at 9:00 A.M. Review of Resident Council Meeting Minutes dated 06/11/19 revealed a concern of not being notified when they had upcoming appointments and being surprised the day of the appointment. Resident #15 attended and voiced the concern in the above meeting. Review of Resident Council Meeting Minutes dated 07/09/19 revealed an appointment notification form was made and that the concern was resolved. During a meeting with Resident Council on 11/05/19 at 3:03 P.M., Resident #15 stated that the facility was still not notifying her of her appointments. She stated she would wake up and staff would inform her she had an appointment the day of. She stated she preferred to have a few days notice. She stated in July 2019 the facility had responded to a concern by making a form, and that nursing staff, who schedule appointments for residents, would give notice to the residents a few days prior to their appointment. She stated this was was not occurring. Interview on 11/05/19 at 3:20 P.M. with the Director of Nursing (DON) revealed she did not think appointment reminders were being implemented by nursing staff. She confirmed nursing staff often scheduled appointments for residents. Interview on 11/05/19 at 3:25 P.M. with Registered Nurse (RN) #137 revealed she had never seen an appointment reminder form for residents and that was not something nursing staff was doing. She confirmed nursing staff often scheduled resident appointments. She stated she was not aware this had been a Resident Council concern. Review of a facility policy, titled, Resident Council and Minutes, dated December 2008, revealed Resident Council would meet monthly. The policy indicated the Activity Director of designee would attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council. Resident issues or concerns would be documented on the Resident/Family Concern Form and forwarded to the facility Administrator for the appropriate follow-up. The policy revealed once the respective department had addressed the Resident/Family concern and documented the outcome, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 2 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 the form would be returned to the Activity Director to file with the Resident Council Meeting Minutes. 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: 365365 If continuation sheet Page 3 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records and staff interviews the facility failed to complete pain interviews on the Minimum Data Set (MDS). This affected two Resident's (#24 and #40) of 14 residents reviewed for comprehensive MDS assessments. The census was 50. Findings include: 1. Review of Resident #24's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, type two diabetes, and a pressure ulcer of sacral region (stage four). Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Section J of the MDS revealed the pain interview should be conducted. Resident #24 received as needed and scheduled pain medication. The resident interview for pain was not assessed. 2. Review of Resident #40's medical record revealed she was admitted to the facility 01/19/16. Diagnoses included acute kidney failure, chronic kidney disease (stage three), and dependence on renal dialysis. Review of Resident #40's MDS dated [DATE] revealed she was cognitively intact. Section J of the MDS revealed the pain interview should be conducted. Resident #40 received as needed and scheduled pain medication. The resident and interview for pain was not assessed. Interview on 11/05/19 at 12:18 P.M. with MDS Licensed Practical Nurse (LPN) #134 confirmed Resident #24's pain interview for his MDS, section J dated 09/16/19 had not been attempted. She stated the facility's corporate nurse was completing MDS's remotely and had been unable to complete resident interviews. Interview on 11/05/19 at 12:41 P.M. with Corporate Regional Nurse (CRN) #162 confirmed the corporate MDS nurse had completed the MDS remotely and that resident interviews were not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 4 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records, staff interview and review of facility policy, the facility failed to screen a resident for serious mental illness and developmental disability. This affected one (Resident #24) of three residents reviewed for appropriate Preadmission Screening and Resident Review (PASRR) completion. The facility census was 50. Residents Affected - Few Findings include: Review of Resident #24's medical record revealed he admitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, type two diabetes, and a pressure ulcer of sacral region (stage four). Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Review of Resident #24's Hospital Exemption Form (7000 Form) dated 07/31/19 revealed the resident could reside in the facility for at least 30 days, pending a PASRR. Further review of Resident #24's medical record lacked evidence a PASRR had been completed. Interview on 11/04/19 at 1:02 P.M. with Social Service Designee (SSD) #136 confirmed that PASRR's should be completed after a 7000 form expires or a resident has a significant change or required a psychiatric hospitalization. Follow up interview on 11/05/19 at 12:00 P.M. with SSD #136 evealed a PASRR was not completed for Resident #24 and should have been completed by 09/07/19. Review of a facility policy titled, Ohio admission PASRR Tracking Protocol, last revised December 2016, revealed if a resident admitted with a Hospital Exemption, the PASRR needed to be completed by the 20th day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 5 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records, staff interviews and review of facility policy, the facility failed to notify the state mental health authority and the intellectual disability authority after a significant change and a psychiatric hospitalization for residents who had mental illness and/or intellectual disability. This affected two Resident's (#36 and #37) of three residents reviewed for appropriate Pre admission Screening and Resident Review (PASRR) completion. The facility identified one resident who had a developmental disability and 20 residents with a documented psychiatric diagnoses. The facility census was 50. Findings include: 1. Review of Resident #36's medical record revealed she admitted to the facility on [DATE]. Diagnoses included: epilepsy, insomnia, mild cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and major depressive disorder with psychotic symptoms. Review of Resident #36's Minimum Data Set (MDS) revealed she was moderately cognitively impaired and was independent with her activities of daily living. Review of a nursing progress note dated 01/15/19 revealed Resident #36 was repetitively speaking, I want to die, I want to die. Resident #36 refused to get out of bed and to toilet and was choosing to soil herself. She had refused meals for multiple days. She continued to be observed by facility staff every 15 minutes. A new order from the physician was received to send Resident #36 to the psychiatric hospital for evaluation and treatment. An additional nursing progress note dated 01/15/19 revealed Resident #36 was en route to the psychiatric hospital. Resident #36 returned to the facility 01/21/19. Review of a PASRR Determination Letter dated 07/12/19 revealed Resident #36 had been referred for a level two screening related to her mental health diagnoses. The determination letter indicated that while Resident #36 had a serious mental illness, she was appropriate for an unspecified amount of time for nursing facility services and did not require specialized services. Further review of Resident #36's medical record lacked evidence a PASRR had been completed after the resident had a psychiatric hospitalization from 01/15/19 through 01/21/19. Interview on 11/04/19 at 1:02 P.M. with Social Service Designee (SSD) #136 confirmed that PASRR's should be completed after a significant change or when a resident had a psychiatric hospitalization. Follow up interview on 11/05/19 at 8:00 A.M. with SSD #136 confirmed a PASRR was never completed after Resident #36's psychiatric hospitalization, and that it was a significant change and a PAS/RR should have been completed. 2. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, schizophrenia, dementia, major depressive disorder, and anxiety disorder. Review of Resident #37's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 6 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 0646 and was independent with her activities of daily living. Level of Harm - Minimal harm or potential for actual harm Review of Resident #36's PASRR Determination dated 10/06/16 revealed Resident #36 had been referred for a level two PAS/RR screening related to her mental health diagnoses. The determination letter revealed while she had a serious mental illness, she was appropriate for the nursing facility and did not require specialized services. Residents Affected - Few Review of a nursing progress note dated 09/21/19 revealed she was transferred to the psychiatric hospital for evaluation and treatment. Further review of Resident #36's medical record lacked evidence a PAS/RR had been completed following her hospitalization from 09/21/19. Interview on 11/04/19 at 1:02 P.M. with SSD #136 confirmed that PASRR's should be completed when a resident has a significant change or required a psychiatric hospitalization. Interview on 11/04/19 at 5:45 P.M. with Social Service Coordinator #116 verified Resident #36 did not have a PASRR completed following her psychiatric hospitalization. Review of a facility policy, titled, Ohio admission PASRR Tracking Protocol, last reviewed December 2016, revealed if a resident is being admitted from a psychiatric unit, a PASRR must be completed prior to the resident being admitted . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 7 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #21 revealed an admission date of 03/11/19 with diagnoses including hypertension, major depressive disorder, atrial fibrillation, insomnia, dementia with behavioral disturbances, muscle weakness, pseudobulbar affect and Alzheimer disease. Residents Affected - Few Review of admission MDS assessment documented the resident had severe cognitive impairment. Further review of staff assessment of daily activity preference documented the resident liked to choose what clothes to wear, caring for personal belongings, receiving a shower, staying up past 8:00 P.M., and family involvement in care discussions. Review of comprehensive care plan documented Resident #21 prefers/enjoys activities including visiting with other residents and staff, walking in the hallway, getting nails done, listening to music and folding clothes. Interventions included to engage Resident #21 in group activities, offer activity program directed towards specific interest/needs of the resident and ensure the resident receives a monthly activity calendar. Review of activities calendar undated documented various activities were schedule on a daily rotating basis including listening to music, looking good, creating a snack, exercise, sing along, trivia, ring toss, group poetry, sensory station, bowling, snacks, afternoon walk with hands on, tell me a story, movement and music, manicures, snacks, indoor outdoor, show time and hands on. During an interview on 11/03/19 at 9:16 A.M. with a family member of Resident #21 revealed there were no activities occurring as scheduled for the secure unit and staff did not bring his mother out to participate in activities off the unit. On 11/04/19 at 1:31 P.M. Resident #21 was observed walking around the unit with no participation in activities. During an interview on 11/04/19 at 3:48 P.M. with Activities Assistance/State Tested Nursing Assistant (STNA) #141 revealed she did not work the weekends and she was not aware of who would conduct activities for Resident #21. She also verified Resident #21 did not participate in any activities off the unit and she was not sure why. She then verified she was not aware there was an activities calendar she was suppose to be following and she just did does what she thought was best for the residents. During an interview on 11/04/19 at 4:31 P.M. with STNA #158 verified activities were not completed as scheduled on 11/03/19 and 11/04/19. She verified staff try to do the best that they can keeping Resident #21 busy with folding laundry. She verified more activities should be occurring as scheduled. Review of policy and procedure titled Activity Program/Calendar policy revised January 2014 documented the facility will offer activities everyday for a minimum of six hours per day and including at least two evenings per week at hours offered at time convent for the residents. These activities will promote physical, cognitive, and/or emotional health that supports residents self expression, exercise, socialization lifestyle programs and leisure pursuits. Based on review of medical record, observation, resident and staff interview, review of activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 8 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 records and review of facility's activity policy, the facility failed to provide activities as scheduled to meet the activity preferences and needs of residents. This affected two Resident's (#21 and #36) of two residents reviewed for activities. The census was 50. Findings include: Residents Affected - Few 1. Review of Resident #36's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included: epilepsy, insomnia, mild cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and major depressive disorder with psychotic symptoms. Review of Resident #36's MDS dated [DATE] revealed she had a moderate cognitive impairment and it was somewhat important to do things with groups of people and to do her favorite activities. Review of Resident #36's care plan, last revised 08/03/18, revealed she enjoyed board games, cards, and talking with others. The care plan indicated her personal preferences would be met as able on a regular basis . Interventions included engaging her in group activities and monitoring her independent activities as needed. Review of an activity progress note,dated 10/18/19 revealed Resident #36 enjoyed playing cards. Review of Resident #36's Activities assessment dated [DATE] revealed Resident #36 enjoyed playing cards and bingo. Interview on 11/03/19 at 9:39 A.M., Resident #36 stated the facility was not following the activity calendar. She stated she enjoyed playing cards and board games. She stated when she goes to the activity room during the scheduled time, they are not doing the scheduled activity and are normally doing something she was not interested in. Observation on 11/03/19 from 10:00 A.M. to 10:30 A.M. revealed there were no residents playing dice. Observation and interview on 11/04/19 from 10:00 A.M.-10:15 A.M. with Activity Staff (AS) #103 revealed AS #103 began to play Farkle at 10:10 A.M. She confirmed Rummy was on the schedule, but that no one in the activity room knew how to play. She confirmed there were residents who were in the facility who enjoyed playing Rummy, and that she did not invite them to play Rummy, nor informed them of the activity schedule change. Follow up interview on 11/04/19 at 10:31 A.M. with AS #103 confirmed it was not documented for any resident that they participated in dice as scheduled 11/03/19. She confirmed they should be marked as refused if they had been asked if they wanted to play. She confirmed there was evidence no resident was invited to nor did dice occur. She stated staff should invite residents to attend activities. Observation and interview on 11/04/19 at 4:15 P.M. with Dietary Manager (DM) #116 revealed she was watching a movie in the activity room with three residents. DM #116 stated AS #103 left the facility at 4:00 P.M., and confirmed that had been when Jenga was scheduled to begin. DM #116 stated she was unsure who was supposed to be leading activities. DM #116 stated the Activity Coordinator was not at the facility. DM #116 confirmed the scheduled activity was not occurring. Review of the November 2019 Activity Calendar for 11/03/19 revealed dice games at 10:00 A.M. Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 9 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 of Unit A and Unit B's activity tracking log, dated 11/03/19, revealed a blank box after board games. The Activity Calendar for 11/04/19 revealed Rummy at 10:00 A.M. and Jenga at 4:00 P.M. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 10 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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** The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, observation, staff interview, review of radiology report, review of fall investigation, review of facility policies and procedures, and review of the facility's corrective action the facility failed to ensure appropriate care and services were provided to a resident during a transfer using a sit to stand lift mechanical device. This resulted in actual harm when Resident #02 fell from the sit to stand lift mechanical device and subsequently sustained a fracture to the right intertrochanteric (hip). This affected one (Resident #02) of one resident reviewed for falls. The facility census was 50. Findings include: Review of the medical record for Resident #02 revealed an admission date of 03/29/17 with diagnoses including diabetes type two, dysphagia, major depression, hypothyroidism, left below the knee amputee, muscle weakness, atrial fibrillation, hypertension, cognitive communication deficit, insomnia, Parkinson's disease, unspecified dementia without any behavioral disturbances Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #02 had moderate cognitive impairments. She was assessed as requiring extensive assistance with two person physical assist for transfers and total assistance with two person assist with toileting. She was also assessed as always incontinent of bowel and bladder. The MDS lacked any documentation of falls since her admission to the facility. Review of the quarterly MDS assessment dated [DATE] documented Resident #02 was cognitively intact without any impairments. Review of the comprehensive care plans revealed Resident #02 did not have any care plan in place to provide her assistance as needed for activities of daily living (ADL) from 04/28/19 through 10/16/19. Review of a physician's order dated 08/07/19 revealed Resident #02 was ordered to be a two person transfer with the sit to stand lift. Review of the nursing note date 10/14/19 at 11:35 A.M. documented State Tested Nursing Assistant (STNA) #144 reported she was transferring Resident #02 with the sit to stand lift and the residents arm slipped out of the lift pad. The resident began to fall from the lift and STNA#144 reported lowering the resident to the ground slowly so the resident would not obtain an injury. STNA #144 then put on the resident's call light for assistance to transfer the resident back in the recliner, so she could be transferred to her wheelchair for lunch. The resident was assessed by the nurse to have no injuries, no neurological deficits and was alert and oriented times three. The family and physician were notified of the fall occurrence. At 6:30 P.M. Resident #02 started to have complaints of right leg pain and bruising was noted to her right lower leg. At 7:37 P.M. an order was obtained for an X-ray of the right hip and leg. Further review lacked any documentation of the resident needing neurological checks related to the fall which was witnessed, and Resident #02 did not hit her head. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 11 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 Review of a physician order dated 10/14/19 revealed to obtain a two view X-ray of Resident #02's right hip and thigh. Further review lacked any order for neurological checks. Level of Harm - Actual harm Residents Affected - Few Review of the radiology report dated 10/14/19 revealed Resident #02 had an acute right intertrochanteric fracture with modest displacement. The joint showed no dislocation. Review of nursing note dated 10/15/19 at 12:05 A.M. revealed the X-ray result came back showing an acute fracture to the right hip. The physician and the daughter were notified, and an ambulance was called to transport Resident #02 to the emergency room (ER) for evaluation. At 5:15 A.M., Resident #02's daughter notified the facility the resident was being admitted to the hospital to have surgery to her right hip. Review of physician order dated 10/15/19 revealed to send Resident #02 to the emergency room for positive right hip X-ray. Review of the facility fall investigation dated 10/14/19 through 10/16/19 revealed the facility completed a thorough investigation surrounding the circumstances involving Resident #02's fall. Through the investigation it was determined through STNA #144's written statement she did not use two nursing staff members to assist with the sit to stand lift as ordered and required per the facility policy while transferring Resident #02. On 10/15/19 the family provided a video of Resident #02's fall for the facility's investigation. STNA #144 was immediately suspended and then terminated based on previously receiving verbal education on 10/12/19 by the Director of Nursing (DON) to use two people for any mechanical lift. Also the video provided by the family revealed STNA #144 did not ensure the residents safety when she failed to use two staff members for the sit to stand lift which resulted in the resident having a right hip fracture. Review of nursing notes dated 10/17/19 at 4:40 P.M. revealed Resident #02 was readmitted to the facility from the hospital after right hip surgery. On 11/03/19 at 3:38 P.M. interview with Administrator verified Resident #02's family had verbalized care concerns with an improper transfer by STNA #144. The family shared a video of the improper transfer. The Administrator verified STNA #144 did not transfer Resident #02 appropriately or safely with the sit to stand mechanical lift. On 11/03/19 at 3:42 P.M. interview with the DON verified STNA #144 did not use the sit to stand lift appropriately when transferring Resident #02. She verified STNA #144 attempted to transfer Resident #02 with only one person assist. The DON indicated, after watching the video, she concluded STNA #144 did not ensure the resident was positioned correctly in the sit to stand mechanical lift to ensure a safe transfer which resulted in Resident #02 falling and sustaining a fractured hip. The DON also verified after watching the video of the incident, provided by the family, STNA #144 was terminated due to her previous verbal education to always use two STNA's for mechanical lift transfers. On 11/04/19 at 12:57 P.M. interview with Resident #02 revealed she did sustain a fall recently when she slipped out of the lift. The resident indicated the fall scared her. On 11/04/19 at 1:21 P.M. interview with STNA #158 verified she was working the day of 10/14/19 when Resident #02 fell. She further verified there were two STNAs (herself and STNA #144) and Licensed Practical Nurse (LPN) #132 working on the secured unit. She revealed STNA #144 never requested assistance to transfer Resident #02. The resident sustained a fall from the sit to stand mechanical lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 12 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 STNA #158 verified when using any lift there should be two staff to assist to ensure the resident's safety. She also revealed she would have been available to help with Resident #02's transfer if STNA #144 had requested assistance. She verified later in the day, Resident #02 had complaints of pain only with movement. She stated she notified LPN #132 and an X-ray was ordered. She denied Resident #02 had constant complaints of pain or any visible bruising to her right hip until later in the evening after the fall occurred. On 11/04/19 at 2:00 P.M. interview with LPN #132 revealed STNA #144 did not ask anyone for assistance to help transfer Resident #02. LPN #132 stated she verbally educated STNA #144 immediately after the incident occurred about using two staff members to transfer Resident #02. LPN #132 revealed after the fall Resident #02 was sitting on the floor with her back against the recliner with her right leg over one of the sit to stand lift leg bases. Initially the resident did not complain of any pain, but later in the evening she started to complain of pain with movement and had visible bruising which was not present on her initial fall assessment. The physician was notified of the pain and an order was received to obtain an X-ray. LPN #132 verified Resident #02 was sent out to the ER after her shift due to the X-ray being positive for a right hip fracture. On 11/05/19 at 2:26 P.M. and 2:37 P.M. an attempt was made to contact STNA #144 who was providing care to Resident #02 when her fall with fracture occurred. STNA #144 was no longer an employee at the facility and contact was not able to be made. Review of facility policy and procedure for fall prevention and fall management dated April 2010 documented a program will identify intrinsic and extrinsic risk factors related to the resident who is at risk for falls. The residents assessment helps to determine the resident's degree of mobility and physical impairment to determine if the resident requires one or two assists for mechanical transfer devices is needed for safe transfer. Review of policy and procedure for comprehensive care planning revised 07/19/19 documented the facility must develop a comprehensive care plan for each of the residents to meet all their needs. The facility had seven days after a comprehensive MDS assessment was complete to initiate or update the care plan as needed. The comprehensive care plan will be reviewed and updated as needed at least every 90 days. Review of the facility's mechanical lift policy revised September 2019 documented two-person assist is required for total body lifts and sit to stand lifts. As a result of the incident the facility took the following actions to correct the deficient practice by 10/24/19: • On 10/14/19, the DON initiated an investigation into the incident. STNA #144 was interviewed and confirmed she had transferred Resident #02 by herself. She also received disciplinary action for not following the appropriate procedure and creating an unsafe environment for the resident. • On 10/15/19, Resident #02's family member provided the facility with video footage of the incident. STNA #144 was placed on suspension pending fall investigation outcome due to new evidence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 13 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 All nursing staff were educated beginning 10/15/19 and ending 10/18/19 regarding ensuring resident care plans identified the need for two persons transfer and proper transfer techniques. The content directed staff to make sure to read and follow each resident's plan of care, and that any resident that required the use of assistive devices such as a mechanical lift or stand-up lift always required the assistance of two staff. Competency evaluation and training regarding staff demonstration of proper use of the stand-up lift for resident transfers was completed for all licensed nurses and STNA's. Residents Affected - Few • On 10/18/19, STNA #144 was terminated due to the improper use of the lift. After review of the video footage the facility felt STNA #144 could have possibly caused more harm by the events that occurred in the video then they initially thought from her statement. • Performance monitoring was initiated on 10/24/19 to maintain ongoing compliance. The facility will audit five residents medical charts every week for four weeks, then five residents medical charts monthly for three months. Results will be reviewed monthly in Quality Assurance Program Improvement (QAPI) meetings. Performance monitoring was completed on 10/24/19 and on 10/31/19 with 100 percent compliance identified. • On 11/03/19, Resident #02 was observed being properly transferred using a Hoyer by two STNAs. • On 11/05/19, Resident #22 was observed being properly transferred with the sit to stand lift. • On 11/05/19, STNA #154 and STNA #158 were interviewed to determine if they had been recently educated regarding the proper use of mechanical lifts and sit to stand lifts. The STNA's were knowledgeable and reported they had been educated on the proper use of sit to stand lifts. Both STNAs reported that they were to always have two nursing staff when transferring residents using a sit to stand lift or any mechanical lift. This deficiency substantiates Complaint Number OH00107781. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 14 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, interview with facility staff, and review of facility policy, the facility failed to ensure ongoing communication with the dialysis center and failed to assess residents post dialysis. This affected one (Resident #40) of one resident reviewed for appropriate dialysis care. The facility identified Resident #40 was the only resident receiving dialysis services. The facility census was 50. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed she admitted to the facility 01/19/16. Diagnoses included acute kidney failure, chronic kidney disease (stage three), and dependence on renal dialysis. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. She required extensive assistance from staff with all activities of daily living. Review of Resident #40's care plan last revised 10/29/19 revealed she received dialysis treatments three times a week and would receive treatments as scheduled with monitoring of disease process. Interventions included maintaining communication with dialysis staff. Review of Resident #40's Dialysis Communication Form dated 09/13/19 to 11/01/19 lacked any post dialysis communication with the dialysis facility, including time of dialysis, post dialysis weight, the amount of fluid removed, her vital signs, pertinent lab draws, or treatments given at dialysis. Interview on 11/04/19 at 2:40 P.M. the Director of Nursing (DON) confirmed post dialysis vitals and dialysis communication was documented in the Dialysis Communication tools in the electronic medical record. She confirmed Resident #40's dialysis assessments, dated 09/13/19 to 11/01/19 lacked evidence of post dialysis communication including: post weight, amount of fluid removed, vitals, medication/treatments provided, and any other pertinent comments from the dialysis center. Review of a facility policy titled, Hemodialysis Care Policy, dated 06/16/17, revealed the nurse should document in the resident's record every shift that dialysis is received: any part of follow-up needed from report from dialysis nurse post dialysis being given, post dialysis observations, post dialysis weights and vitals and any condition change. The policy revealed most problems that arise with hemodialysis occur during dialysis or immediately afterwards and to communicate with the dialysis center for the needed documentation to care for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 15 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 interview the facility failed to ensure non pharmacological interventions were implemented before giving an as needed narcotic (Percocet). This affected one (Resident #40) out of five residents reviewed for unnecessary medications. The facility census was 50. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed she was admitted to the facility on [DATE] with diagnoses of heart failure, respiratory failure, kidney disease (stage 3), schizophrenia, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. Her functional status was listed as totally dependent for transfers and toileting. Review of the care plan dated 06/05/19 revealed the resident used psychotropic medications daily related to diagnosis of anxiety disorder and depression. Review of the Medication Administration Record (MAR) dated for 10/2019 and 11/2019 revealed Resident #40 was administered Percocet (for pain) nine times (10/02/19, 10/03/19, 10/14/19, 10/18/19 two times on 10/21/19, 10/22/19, 10/28/19, 10/31/19) and one time on 11/01/19 without non pharmacological interventions being attempted. Interview with the Corporate Registered Nurse #162 on 11/05/19 at 2:00 P.M. confirmed no non-pharmacological interventions were attempted prior to giving an as needed narcotic. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 16 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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** 2. Resident #27 admitted to the facility from the hospital 06/19/19 with an indwelling catheter. Residents Affected - Many Review of Resident #27's MDS dated [DATE] revealed he was cognitively intact, required extensive assistance from staff with toilet use, had an indwelling catheter, and was always incontinent of his bowels. The resident had onset of urinary symptoms including bloody drainage on 07/03/19. Review of laboratory testing on 08/01/19 and 08/05/19 revealed the resident had Escherichia coli (E. coli). He was treated with antibiotics from 08/05/19 to 08/11/19, 08/16/19 to 08/19/19, and 08/24/19 to 09/02/19. Resident #27's room was adjacent to Resident #41 and down the hall from Resident #99, Resident #147, and Resident #35. 3. Resident #41 admitted to the facility on [DATE]. Review of Resident #41's MDS, dated [DATE], revealed she was cognitively intact, required extensive assistance from staff with toilet use, and was always incontinent of bowel and bladder. The resident had onset of urinary symptoms began 07/18/19 with repeat laboratory testing requested 08/02/19. Cultures of her urine, dated 08/04/19, revealed an E. coli infection. She was treated with antibiotics from 08/05/19 to 08/11/19 Resident #41's room was adjacent to Resident #27, Resident #35, Resident #147, and Resident #99. 4. Resident #98's closed record revealed she was admitted to the facility 07/25/19. Review of her MDS dated [DATE] revealed she was cognitively intact, required extensive (two-plus staff) assistance with toileting, was frequently incontinent of her bladder and occasionally incontinent of her bowels. Resident #98's laboratory tests dated 07/29/19 revealed Enterobacter cloacae. Onset of her urinary tract infection symptoms began 07/29/19. She received antibiotics from 08/02/19 to 08/12/19. Resident #98's room was adjacent to Resident #27's room. 5. Resident #40 admitted to the facility on [DATE]. Review of Resident #40's discharge MDS dated [DATE] revealed she had a moderate cognitive impairment, was totally dependent on staff for toilet use, had an indwelling catheter, and was always incontinent of her bowels. She transferred to the hospital on [DATE]. Her onset of urinary tract infection symptoms began on 08/06/19. Resident #40 re-admitted to the facility on [DATE] with a diagnosis of urinary tract infection. Laboratory testing was completed in the hospital. Resident #40 received antibiotics from 08/18/19 to 08/27/19 Resident #40's room was next door to Resident #14. 6. Resident #99 admitted from the hospital on [DATE]. Review of MDS dated [DATE] revealed he was cognitively intact, required extensive assist with toilet use, had an indwelling catheter, and was frequently incontinent of his bowels. His urinary symptoms began 08/08/19. Laboratory tests dated 08/14/19 revealed Methicillin resistant Staphylococcus aureaus (MRSA). He was treated with an antibiotic from 08/15/19 to 08/26/19. Resident #99 shared a room with Resident #147. The next room to the right was Resident #35's room. Resident #127's room was three rooms to the right from Resident #99. 7. Resident #147 admitted to the facility on [DATE]. Review of Resident #147's MDS dated [DATE], revealed she was cognitively intact, required extensive (two-plus) person assist from staff with toileting, and was always continent of bowel and bladder. She discharged to the hospital on [DATE] and returned 08/08/19 with symptoms of a urinary tract infection. She was treated with antibiotics from 08/08/19 to 08/10/19, and an alternative antibiotic from 08/17/19 to 08/18/19. On 08/14/19, laboratory results revealed Acinetobacter and providencia stuarti. laboratory results dated [DATE] revealed klebsiella pneumoniae. Resident #147 experienced re-occurring urinary tract infection symptoms on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 17 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 09/06/19. Laboratory results 09/06/19 revealed klebsiella pneumonae, and probable non-hem strep. Resident #147's room was shared with Resident #99 and was next to Resident #35. One room down the hall from Resident #147 was Resident #27. Her room was adjacent to Resident #41's room. 8. Resident #35 admitted to the facility 03/28/17. Review of her MDS dated [DATE] revealed she was cognitively intact, required extensive two-plus person assist with toileting, and was frequently incontinent of bowel and bladder. The onset of her urinary tract infection symptoms, including pain with urination, began 08/15/19. She was treated with antibiotics from 08/16/19 to 08/26/19. Resident #35 had re-occurring urinary tract infection symptoms beginning 09/05/19 and received antibiotics from 09/06/19 to 09/12/19. Resident #35's room was next door to Resident #99 and Resident #47 and was adjacent to Resident #41. 9. Resident #18 admitted to the facility 03/14/18. Review of Resident #18's MDS dated [DATE] revealed she had a severe cognitive impairment, required extensive assistance (two-person-plus) from staff for toileting, and was always incontinent of bowel and bladder. She was transferred to the hospital on [DATE]. She returned from the hospital on [DATE]. The onset of her urinary symptoms was 08/15/19. She was treated with antibiotics from 08/16/19 to 09/02/19. Laboratory tests completed 08/23/19 revealed enterococcus. Resident #18's room was across the hall from Resident #39. 10. Resident #39 admitted to the facility 04/19/19. Resident #39's MDS dated [DATE] revealed she was severely cognitively impaired, required extensive (two-plus person) assistance from staff with toilet use, and was always incontinent of both bowel and bladder. The onset of her urinary tract infection symptoms began 08/21/19. laboratory results dated [DATE] revealed E. coli. Resident #39 received antibiotics from 08/24/19 to 08/31/19. Resident #39's room was across the hall from Resident #18. 11. Resident #14 admitted to the facility on [DATE]. Resident #14's MDS dated [DATE] revealed she was cognitively intact, required extensive assistance with toilet use, was occasionally incontinent of bladder and was frequently incontinent of her bowels. The onset of her urinary tract infection symptoms began 08/25/19. Her symptoms included dysuria. Laboratory tests dated 08/27/19 revealed E. coli and probable non-hem strep. She was treated with antibiotics from 08/29/19 to 09/02/19. Resident #14's room was next to Resident #40. 12. Resident #46 admitted to the facility 12/12/15. Review of Resident #46's MDS dated [DATE] revealed she was cognitively intact, required extensive assistance with toilet use, and was frequently incontinent of both bowel and bladder. The onset of her urinary symptoms began 09/18/19. laboratory results dated [DATE] revealed E. coli. She was treated with antibiotics from 09/23/19 to 09/28/19. Resident #46's room was across the hall from Resident #14 and Resident #40. Interview on 11/05/19 at 3:44 P.M. with the DON and Corporate Registered Nurse (CRN) #162 confirmed there was a pattern of urinary tract infections in the facility in August 2019. They confirmed 10 urinary tract infections in August 2019, and an additional resident (#46) in a nearby room had an infection September 2019. Both confirmed there had been no follow-up or interventions/education put into place to prevent further infection. Review of the facility's Antibiotic Use Tracking Sheet, dated August 2019, lacked evidence infection control and prevention surveillance had been completed. Review of a facility policy, titled, Infection Prevention and Control Program, dated 07/19/19, revealed it was the policy of the facility to maintain an organized, effective facility-wide program (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 18 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many designed to systematically prevent, identify, and control and reduce the risk of acquiring and transmitting infections. The policy stated the Infection Preventions would conduct surveillance for facility associated infections and assure compliance with State and Federal regulations. The policy stated the facility would participate in performance improvement activities by promoting enhanced hand hygiene and adherence to respiratory hygiene/cough etiquette. Further review of the policy revealed the Infection Preventionist would provide education to staff based on surveillance of findings and as appropriate. 13. Review of Resident #24's medical record revealed he admitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, type two diabetes, and a pressure ulcer of sacral region (stage four). Review of Resident #24's MDS, dated [DATE], revealed he was cognitively intact. Review of Resident #24's care plan, dated 10/25/19, revealed Resident #24 had an infection of the coccyx wound and was being treated with antibiotics. Interventions included maintaining universal precautions when providing resident care. Observation on 11/04/19 at 4:00 P.M. with MDS/Licensed Practical Nurse (LPN) #134 and STNA #145 of wound care for Resident #24, revealed MDS-LPN #134 washed her hands and gloved before removing the old dressing. She removed the old dressing and began cleaning the wound with the same gloves she used to remove the old dressing. She then put on new gloves, without washing her hands or using sanitizer, and applied the Calcium Alginate, skin prep and covered the wound with a Meplex, and rewashed her hands as ordered. Interview with CRN #162 on 11/04/19 at 5:00 P.M. confirmed LPN #134 should have washed her hands and applied new gloves before cleaning Resident #24's wound. Review of a facility policy titled, Wound and Dressing Care, undated, revealed clean technique, should be used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. The policy stated clean technique involved meticulous hand-washing, maintaining a clean environment by preparing a clean field, using clean gloves, sterile instruments, and prevention of direct contamination of materials and supplies. Based on medical record review, observation, staff interview, and review of facility's infection policies and infection control log, the facility failed to identify and implement interventions to correct a concern with urinary tract infections as well as complete infection surveillance for August 2019. This affected 11 Residents (#14, #18, #27, #35, #39, #40, #41, #46, #98, #99, and #147) of 11 reviewed for infections. In addition the facility failed to ensure proper hand hygiene during wound care. This affected one (Resident #24) of one resident reviewed for wound care. The facility also failed to ensure proper food handling, related to hand hygiene, before touching residents food. This directly affected one (Resident #13) of one resident observed during a lunch observation. This had the potential to affect all 50 residents. The facility census was 50. Findings include: 1. Review Resident #13's medical record revealed she was admitted to the facility on [DATE] with diagnoses of hypertension, repeated falls, age related cognitive decline and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 19 of 20 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had mild cognitive impairment. Her functional status was listed as extensive one person assists for all activities of daily living except eating and she was independent set up only. Observation with the Director of Nursing (DON) on 11/03/19 at 11:50 A.M. of lunch trays being passed out, by State Tested Nursing Assistant (STNA) #157 revealed the STNA had a sore with an adhesive dressing on her right middle finger. STNA #157 picked up Resident #13's roll with her hand, ungloved, and buttered the resident's dinner roll. Interview with the DON at the time of the observation confirmed the STNA should have had gloves on her hands before touching Resident #13's food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 20 of 20