Inspection·October 13, 2022

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Potential for minimal harm Based on staff interview and record review, the facility failed to ensure the resident's fund accounts were provided a monthly interest. This affected three (Residents #26, #38, and #42) of six residents reviewed for resident funds. The facility census was 46. Residents Affected - Some Findings include 1. Review of the medical record for Resident #26 revealed an admission date of 03/13/17. Diagnoses included anxiety and Alzheimer's disease. Review of Resident #26's fund statements revealed Resident #26 did not receive interest in 06/2022 with a balance of $465.62, in 07/2022 with a balance of #225.62, in 08/2022 with a balance of $275.62, and in 09/2022 with a balance of $325.62. 2. Review of the medical record for Resident #38 revealed an admission date of 03/26/15. Diagnoses included chronic kidney disease and contracture of right and left hand. Review of Resident #38's fund statements revealed Resident #38 did not receive interest in 03/2022 with a balance of $275.62 and in 07/2022 with a balance of $275.62. 3. Review of the medical record for Resident #42 revealed an admission date of 07/18/18. Diagnoses included joint pain, epilepsy, dysphasia, cognitive impairment, and non-compliance. Review of Resident #42's fund statements revealed Resident #42 did not receive interest in 02/2022 with a balance of $121.62. Interview on 10/12/22 at 2:00 P.M. with Business Office Manager (BOM) #527 revealed if residents have money in their account, they should be getting interest on that money. BOM #527 stated the computer dictates and divides the interest. BOM #527 confirmed Resident #26 did not receive interest from 06/2022 through 09/2022. BOM #527 confirmed Resident #38 did not receive interest on 03/2022 and 07/2022. BOM #527 confirmed Resident #42 did not receive interest on 02/2022. Review of the letter from the banking agency titled 'Corporation #600' dated 10/12/22 revealed the resident interest was accrued daily and added to their accounts monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of the facility's policy, and record review, the facility failed to timely provide a spend-down notification to a resident or representative and assist the resident in spending their balance before returning it to the State of Ohio. This affected one (Resident #22) of one resident reviewed for spend-down notifications. The facility census was 46. Residents Affected - Few Finding include Review of the medical record for Resident #22 revealed an admission date of 03/07/14. Diagnoses included non-psychotic mental disorder and cognitive communication difficulty. Review of the spend-down notification dated 01/04/22 revealed Resident #22's balance was within $200 of the Medicaid limit or higher. This notification was to inform Resident #22 of the balance amount and provide information to reach out to the social worker within seven days to work out a plan to spend the balance. There was no evidence Resident #22 or representative were provided a spend-down notification in the year of 2021. Review of Resident #22's account statement dated 01/04/22 revealed a balance of $4,322.98. The statement also revealed on 01/05/22 a balance of $2,500.00 was a lump sum to state and it was withdrawn from Resident #22's account and returned back to the State of Ohio. Interview on 10/12/22 at 2:00 P.M. with Business Office Manager (BOM) #527 revealed Resident #22 had a history of being over-resourced and had been given spend-down notifications in 02/2021, 03/2021, 04/2021, 06/2021, and 07/2021. BOM #527 confirmed Resident #22 was not given another spend-down notification until 01/04/22. BOM #527 confirmed the facility does not have a copy of a signed spend-down notification to Resident #22 and/or resident representative and had no evidence of working with Resident #22 and/or representative to spend her resources before they were returned to the State of Ohio. BOM #527 also confirmed the spend-down notification informs the resident to contact the social worker within seven days for resolution, and was given the notice only one day prior to the funds being returned. Review of the facility's undated policy titled Resident Fund Management Program, revealed there was no process or mention related to spend-down notifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the facility's policy, observations, and record review, the facility failed to ensure a care plan was created related to resident's oxygen use and behaviors. This affected one (Resident #11) of one resident reviewed for care plans. The facility census was 46. Finding include: Review of the medical record for Resident #11 revealed an admission date of 06/21/22. Diagnoses included hypertension, edema, heart disease, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Review of Resident #11's care plan dated 07/17/22 revealed there was no mention of Resident #11 being on oxygen nor any mention of Resident #11's behaviors of pulling her oxygen out of her nose. Review of the physician orders dated 08/08/22 revealed an order for oxygen at two liters per nasal cannula for shortness of breath (SOB) and to keep oxygen saturations over 92 percent. The physician order dated 10/08/22 revealed an order for two liters of oxygen and to check and document the oxygen saturations each shift. Observation on 10/11/22 at 10:03 A.M. revealed Resident #11 was sleeping with oxygen through the nasal cannula and the nasal cannula was located above her nose on her forehead. Interview with Licensed Practical Nurse (LPN) #538 on 10/11/22 at 10:05 A.M. stated Resident #11 had behaviors and regularly takes off her oxygen and moves it up on her face. Observation on 10/11/22 at 11:23 A.M. revealed Resident #11's nasal cannula was located above her nose on her her forehead. Staff were observed to bring Resident #11 her lunch tray and adjusted her nasal canual at her nose for Resident #11 to receive oxygen. Interview on 10/12/22 at 9:00 A.M. with Registered Nurse (RN) #512 revealed Resident #11 had behaviors of her removing her oxygen and her oxygen saturations will drop into the 70s percent range fairly quickly when not on oxygen. Interview on 10/12/22 at 9:50 A.M. with the Director of Nursing (DON) stated Resident #11 pulls off her oxygen and was not compliant with wearing it in her nose. The DON verified Resident #11's oxygen use should be care planned. Interview on 10/12/22 at 3:42 P.M. with LPN #540 verified Resident #11's oxygen use and behaviors were not listed in the care plan. Review of the facility's policy titled Comprehensive Care Planning, dated 07/19/19, revealed the facility would establish a comprehensive care plan for each resident. In cases of significant changes in the residents' condition, the care plan should be updated within seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy, and staff interview, the facility failed to timely implement a wound treatment for a resident's new pressure ulcer. This affected one (Resident #15) of three residents reviewed for pressure wounds. The facility identified two current residents with pressure ulcers. The facility census was 46. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/15/16. Diagnoses included functional quadriplegia, flaccid neuropathic bladder, obstructive and reflux uropathy, chronic pain, chronic obstructive pulmonary disease, sepsis, cutaneous abscess of back, open wound of lower back and pelvis, depression, pressure ulcer of right buttocks stage four (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed), and multiple sclerosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required total dependence from staff for activities of daily living. Review of the Wound Management Group's progress note dated 09/28/22 revealed a new stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to Resident #15's left ischium measuring 2.1 centimeters (cm) in length by 1.3 cm in height by 0.1 cm depth. The treatment should include Alginate Calcium with silver every two days for thirty days. Review of the Wound Management Group's progress note dated 10/05/22 revealed the stage three pressure ulcer to the left ischium measured 1.0 cm by 0.7 cm by 0.1 cm. The wound had improved. The treatment should include Alginate Calcium with silver every two days for twenty three days. Review of Resident #15's physician orders from 09/28/22 through 10/11/22 revealed there was no treatment order for the pressure ulcer on the left ischium. Interview on 10/12/22 at 8:20 A.M. with the Director of Nursing (DON) verified Resident #15 did not have a physician-ordered treatment for Resident #15's pressure ulcer to the left ischium. Review of the facility's policy titled Skin and Wound Care Best Practices, revised 06/10/22, revealed pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, observations, and record review, the facility failed to ensure staff placed a splint device on a resident according to the therapy recommendations and physician order. This affected one (Resident #30) of one resident reviewed for positioning and mobility. The facility identified two residents with a physician-ordered splint device. The facility census was 46. Finding include: Review of the medical record for Resident #30 revealed an admission date of 11/21/19. Diagnoses included stiffness of the joint, lack of coordination, and hemiplegia and hemiparesis affecting her right side. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had an upper extremity impairment to the one side. Resident #30 did not have refusal of care during the assessment reference days. Review of the care plan dated 04/14/22 revealed Resident #30 had a right hand splint for a contracture management with staff to don (apply) the splint with interventions to wear the devices as indicated once daily. There was no mention of Resident #30 refusing to wear her splint device. Review of the physician order dated 08/28/22 revealed Resident #30 was to wear a right resting hand orthotic for up to eight hours daily with no signs of skin breakdown. Review of the therapy evaluation dated 09/12/22 revealed a recommendation for Resident #30 to wear a right-hand splint to maintain proper alignment. Review of the treatment administration record (TAR) dated 10/2022 revealed Resident #30 had been marked off as wearing the splint each day from 10/01/22 to 10/12/22. Observation and interview on 10/11/22 at 9:10 A.M. of Resident #30 revealed the splint was located on her chair. Resident #30 reported she was supposed to wear the splint daily but required the staff to put it on her and they have not offered it in several days. Observation on 10/11/22 at 10:20 A.M., 11:34 A.M., 2:10 P.M., and 4:03 P.M. revealed Resident #30's wrist splint was observed sitting in her chair in the same spot since the previous observations. Observation on 10/12/22 at 8:56 A.M., 11:40 A.M., 1:55 P.M., and 5:38 P.M. revealed Resident #30's upper extremity splint was sitting on her chair. At no time was Resident #30 observed to be wearing the splint. Interview on 10/12/22 at 5:40 P.M. with Registered Nurse (RN) #512 revealed she had no seen Resident #30 wearing the brace during her shift. RN #512 stated she worked since 6:00 A.M. on 10/12/22. RN #512 was unsure why the brace was signed off on the TAR as being worn and range of motion care being provided. RN #512 stated therapy likely placed and removed the brace daily for Resident #30. Interview on 10/12/22 at 5:44 P.M. with State Tested Nursing Aide (STNA) #514 revealed she had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seen Resident #30 wearing a splint today (10/12/22) on the upper right extremity. STNA #514 denied offering to place a brace on Resident #30 during her shift on 10/12/22. Interview on 10/12/22 at 5:53 P.M. with the Director of Nursing (DON) and Administrator revealed no knowledge of Resident #30's splint not being donned according to the physician order and therapy recommendation. The DON and Administrator stated Resident #30 had a history of refusals of care, but the TAR should reflect all refusals and not be marked as if the splint was being worn. Interview on 10/13/22 at 8:24 A.M. with Occupational Therapy (OT) #551 revealed Resident #30 was discharged from services on 10/11/22 and was not evaluated or seen by therapy on 10/11/22 or 10/12/22. OT #551 stated therapy staff would not be placing and removing a resident's splint as services had ended. OT #551 stated it had been the staff's responsibility to follow the physician order and therapy recommendations accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 - 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 observations, review of the facility policy, record review, and resident and staff interview, the facility failed to ensure smokeless tobacco products were secured. This affected one (Resident #23) of one resident reviewed for smoking. The facility identified one resident who wandered and had cognitive impairment. The facility census was 46. Findings include: Review of the medical record for Resident #23 revealed an admission date of 12/18/18. Diagnoses included cognitive communication deficit, paraplegia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Resident #23 required extensive assist of two staff for bed mobility and transfers. Resident #23 required total dependence of one for bathing, dressing, and toileting. Review of the care plan dated 07/16/22 revealed Resident #23 was a supervised smoker. The goals included the resident would maintain a safe smoking environment as evidence by not smoking violations through the next review. Interventions included the resident would initiate smoking contract upon admission and as needed, educate on smoking risks, staff to complete smoking assessment to ensure safety, and staff to keep tobacco products, cigarettes, lighter, and matches in a designated location and dispense during smoking times. Observation on 10/11/22 at 10:15 A.M. revealed Resident #23 had a can of smokeless tobacco (snuff) on his bedside table in his room. Subsequent observation on 10/11/22 at 4:03 P.M. revealed Resident #23 had a can of snuff at bedside. Interview on 10/11/22 at 4:03 P.M. with Resident #23 stated he goes outside every once in awhile for a cigar. Resident #23 stated the residents can use the pouch of tobacco now instead. Observation on 10/12/22 at 11:46 A.M. revealed Resident #23 continued to have a can of snuff at bedside. Interview on 10/12/22 at 2:24 P.M. with the Director of Nursing (DON) stated Resident #23 was not supposed to have snuff at bedside. The DON verified the facility's smoking policy stated all tobacco products were to be locked up and given to residents at smoke times. The DON verified snuff in Resident #23's room and confiscated the tobacco. Interview on 10/12/22 at 2:39 P.M. with Registered Nurse (RN) #512 stated they had seen snuff in Resident #23's room. RN #512 stated Resident #23 had snuff in room for at least two weeks. Observation on 10/13/22 at 8:47 A.M. revealed Resident #23 had a can of snuff at bedside. Interview on 10/13/22 at 10:29 A.M. with State Tested Nursing Assistant (STNA) #502 stated Resident #23 had snuff in their room. STNA #502 stated they assumed the resident was care planned to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 snuff in their room. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Resident Smoking Policy, revised 06/20/22, revealed smoking includes use of all cigarettes, cigars, pipes, vapes, e-cigarettes, hookahs, snuff, chewing tobacco or any other form of inhalation/ingestion of nicotine and/or other similar substances. No resident will maintain or store smoking materials on their person or in their room. Resident smoking materials will be retained by facility staff and distributed to the residents or supervising staff at designated smoking times. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to timely act on pharmacy recommendations for three (#2, #10, and #14) of five residents reviewed for unnecessary medications. The facility census was 46. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and gastrointestinal symptoms. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and delusions. Review of the pharmacy recommendation dated 06/14/22 revealed Resident #2 received a Omeprazole 20 milligrams (mg) (proton pump inhibitor) in addition to another gastro protective therapy Cimetidine 200 mg once a day. The pharmacist recommended to discontinue Cimetidine. The physician declined recommendation and wrote the Cimetidine was for sexual behavior, The physician note on the pharmacy recommendation was dated 06/22/22. Review of the pharmacy recommendation dated 07/19/22 revealed medication Cimetidine has an inappropriate supporting diagnoses or indication for use of gastroesophagela reflux disease (GERD). The response to the pharmacy recommendation on 06/14/22 stated Cimetidine was used to treat sexual aggression/behaviors. Please review and add the appropriate indication for use of Cimetidine. The recommendation was signed by the Director of Nursing (DON) on 07/26/22. Review of the October 2022 medication administration record (MAR) revealed Resident #2 was receiving Cimetidine 200 mg dispense as written give one tablet by mouth at bedtime daily for GERD dated 07/26/22. During an interview with the DON on 10/12/22 at 3:56 P.M., the DON confirmed the facility had not timely acted on the pharmacy recommendation for Resident #2 regarding the indication of use for the medication Cimetidine. 2. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety disorder and dementia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 was cognitively impaired, had no behaviors, and received seven days of antianxiety medication. Review of the pharmacy recommendation dated 05/05/22 revealed the pharmacist stated Resident #10 received two or more anxiolytic medications concomitantly, which may increase the additive central nervous system effects and risk for adverse events. Buspar (buspirone) five mg once a day and Hydroxyzine Hydrochloride 10 mg twice a day for anxiety. The pharmacist recommended to consider discontinuation of Hydroxyzine HCL and adjusting the Buspar (buspirone) dose as necessary to treat anxiety. The recommendation had checked to accept the pharmacist recommendation with modifications of discontinue Buspar. The physician signed the modification and acceptance of the recommendation two months later (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0756 on 07/07/22. Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy recommendation dated 06/14/22 revealed the pharmacist stated Resident #10 received two or more anxiolytic medications concomitantly, which may increase the additive central nervous system effects and risk for adverse events: Buspar five mg once a day and Hydroxyzine Hydrochloride 10 mg twice a day for anxiety. The pharmacist recommended to discontinue Hydroxyzine HCL and adjust the Buspar dose as necessary to treat anxiety. The facility had a note on the bottom or the recommendation which stated Duplicate of May- Forwarded to Psychiatrist, Psychiatrist returned the May recommendation. Residents Affected - Few Review of the May 2022 and June 2022 medication administration record revealed Resident #10 continued to receive both the Buspar five mg daily and the Hydroxyzine Hydrochloride 10 mg twice a day during these months. The June 2022 MAR revealed the Buspar five mg had a discontinuation date of 07/07/22. During an interview with the Director of Nursing (DON) on 10/12/22 at 10:28 A.M., the DON confirmed the pharmacy recommendation written in May was not timely addressed. The DON stated the facility was waiting for the psychiatrist to address the recommendation and the DON agreed two months was a long time to wait for a recommendation to be addressed. 3. Review of the medical record for Resident #14 revealed an admission date of 04/01/20. Diagnoses included bipolar, anxiety, depression, schizophrenia, and paranoia. Review of the MDS assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of the physician order dated 06/30/21 to 07/21/22 revealed an order for Sertraline (antidepressant) 25 mg to be administered once daily. A second physician order dated 06/30/21 to 07/21/22 revealed an order for 50 mg Sertraline to be administered once daily. Review of the pharmacy recommendation dated 03/10/22 revealed Resident #14 had orders for Sertraline 75 mg daily for depression symptoms since 06/2021 with a recommendation to attempt a dose reduction or provide reasoning why a dose reduction would be contraindicated. The physician marked declined and wrote a comment stable. The Pharmacy recommendation revealed it was a repeat recommendation from 01/12/22 that had not been responded to. Interview on 10/13/22 at 2:16 P.M. with the DON confirmed the pharmacy recommendation dated 01/12/22 regarding sertraline medications was unable to located by the facility staff. Review of the policy titled Medication Regime Review (MRR), dated 12/01/07 with a revision date of 03/03/20 revealed the procedure included: the Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or the attending physician and to the Medical Director. Facility staff should ensure the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs. The facility should encourage the physician/prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any. action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm rationale in the residents' health record. The facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner. If an irregularity does not require urgent action but should be addressed before the consultant pharmacist's next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician responses to identified irregularities based on the specific resident's clinical condition. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to attempt a gradual dose reduction (GDR) or provide a rationale for not attempting a GDR for a resident receiving an antidepressant. This affected one (Resident #14) of five residents reviewed for unnecessary medications. The facility census was 46. Findings include: Review of the medical record for Resident #14 revealed an admission date of 04/01/20. Diagnoses included depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of the physician order dated 06/30/21 to 07/21/22 revealed an order for Sertraline (antidepressant) 25 mg to be administered once daily. A second physician order dated 06/30/21 to 07/21/22 revealed an order for 50 mg Sertraline to be administered once daily. Further review of Resident #14's medical record revealed there was no evidence the physician attempted a GDR for Sertraline or an explanation of why the GDR was not attempted for the use of Sertraline. Interview on 10/13/22 at 2:16 P.M. with the Director of Nursing (DON) confirmed Resident #14's medical record did not have evidence of any GDR was attempted or reasoning why it was not attempted for the use of Sertraline. Review of the facility policy titled Medication Regimen Review, dated 03/03/20, revealed the issues that require a physician intervention, the facility should encourage the physician to either accept and act on the recommendations or reject the recommendations and provide explanation as to why the recommendation was being rejected. The physician should document in the resident's health record that the irregularity has been reviewed and what if any action was being done. If the physician has decided to take make no changes, a rationale should be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 13 of 13