Inspection·June 10, 2025

F 0550 bed mobility and she was a Hoyer lift for transfers. She was always incontinent for bowel and bladder. Level of Harm - Minimal harm or potential for actual harm Review of the facility provided designated smoke times revealed the residents are allowed to smoke at: 9:00 A.M., 11:00 A.M., 1:00 P.M., 4:00 P.M. and 9:00 P.M. daily. Residents Affected - Few Review of Resident/Family Council Agenda/Minutes from 03/02/25, 03/11/25, 03/19/25, 04/08/25, 04/22/25, and 05/13/25 revealed there was no documentation included in the old business section of the minutes to address the request of the additional smoke break time from meeting held on 02/11/25, and there was no other concern documented regarding the times of resident smoke breaks on the minutes reviewed. Review of resident council minutes dated 02/11/25 revealed the council wanted to add another smoke break to the schedule of smoking times between 4:00 P.M. and 9:00 P.M. Review of current smoking times for the supervised smokers revealed there wasn't any between 4:00 P.M. and 9:00 P.M. Interview with Resident #35 on 06/04/25 at 11:01 A.M. revealed the council had asked for an additional smoking break back in February council meeting and it has not been set up yet. Interview with Activities Director (AD) #236 on 06/04/25 at 1:50 P.M. revealed there wasn't enough staff (even though the smoking times were divided up between other members of staff throughout the facility) to be able to provide another smoking break for the supervised smokers at 7:00 P.M. She revealed she had a new staff member starting on 06/04/25 and she would be trained to take out the supervised smokers at 7:00 P.M. Review of the policy entitled Residents Rights not dated revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Based medical record review, observation, staff and resident interview and the facility policy review, the facility failed to honor one resident's (#22) request for a smoking break of one resident reviewed for supervised smoking. The facility identified seven residents who required supervised smoking. In addition the facility failed to timely address and ensure the request for an additional smoke break was resolved for two (#29 and #35) of two residents reviewed for resident rights. The facility census was 46. Findings Included: Review of record for Resident #22 revealed admission date of 07/03/24. Diagnoses included neuromuscular dysfunction of bladder, depression, and nicotine dependence using cigarettes. Review of plan of care dated 08/12/24 revealed Resident #22 had a safe smoking environment by not having smoking violations through next review. Interventions included staff to keep smoking products, completing smoking assessment, orient and review with resident the smoking policy times, observe clothing and skin for burns, and notify staff immediately if resident was suspected in violating smoking policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 2 of 32 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 06/10/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility smoking assessment dated [DATE] revealed Resident #22 required a supervision during smoke breaks. Interview on 06/05/25 at 8:30 A.M. with Resident #22 revealed who stated that she had never got her smoke break on 06/04/25 which requested from the Social Services (SS) #333 yesterday. Resident #22 stated that she waited on the side of the bed for a half hour, and no staff came to transfer her into a wheelchair and take her to the smoke break. Interview on 06/05/25 at 8:40 A.M. with SS #333 revealed she did not tell any staff to take Resident #22 out for her smoke break. SS #333 stated she had sent a group text out to management with the information. SS #33 stated the resident should have had a smoke break yesterday after she spoke to the resident around 4:15 P.M. and let management staff be aware the resident wanted a smoke break. Interview on 06/05/25 at 8:45 A.M. with Administrator who revealed she was aware that Resident #22 wanted a smoke break on 06/04/25, the Administrator stated she was handling another situation, and thought the smoking need with Resident #22 was resolved. Review of the facility policy titled Resident Smoking Policy dated 06/20/22 revealed the facility had established resident smoking processes that took into account both smoking and non-smoking residents and that comply with applicable federal, state, and local laws and regulation regarding smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 3 of 32 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 06/10/2025 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, staff and resident interviews, and facility policy review, the facility failed to ensure staff provided dignity and respect to two residents (#22 and #21) of two residents reviewed for dignity and respect. The facility census was 46. Findings Included: Review of record for Resident #22 revealed admission dated 07/03/24. Diagnoses included neuromuscular dysfunction of bladder, depression, and nicotine dependence using cigarettes. Review of plan of care dated 08/01/24 revealed Resident #22 had risk for altered mood related to depression. Interventions included assisting residents in identify strengths, positive coping skills, anger management, approach in a calm relaxed manner, and collaborative care. Interview on 06/04/25 at 3:30 P.M. Resident #22 stated that Certified Nursing Assistant (CNA) #240 had a conversation during care, and CNA #240 was inappropriate to her. Resident #22 stated CNA #240 had lifted her own breasts with her hands outside her shirt. Resident #22 stated CNA #240 was trying to be funny, but Resident #22 stated she did not take it as funny. Resident #22 stated this happened a month ago. Interview on 06/04/25 at 3:42 P.M. with CNA #240 who stated she did make a gesture to Resident #22 one time by lifting her breasts with her two hands over her shirt in front of Resident #22 while providing care for her. CNA #240 stated she was trying to be funny and was talking about her breast. Interview on 06/04/25 at 4:10 P.M. with Administrator revealed she would give education to CNA #240 who needed more education, the CNA was written up, and was sent home. Administrator stated it was inappropriate to act this way to a resident at the facility. 2. Medical record review for Resident #21 revealed an admission date of 06/25/21. Medical diagnoses included non-traumatic brain dysfunction. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was severely cognitively impaired with memory problems. Her functional status was dependent for eating, toilet use, bed mobility and she required a Hoyer lift for transfers. The resident was always incontinent for bowel and bladder. Observation on 06/03/25 at 11:00 A.M. revealed Resident #21 was sitting in the dining room in a wheelchair. Certified Nursing Aide (CNA) #222 placed a clothing protector onto the resident and didn't ask or have an interaction with the resident while placing the protector onto the resident. Also during the observation CNA #206 said out loud Resident #21 was the only true feed in the dining room. Interview with CNA #206 on 06/03/25 at 11:05 A.M. confirmed he called Resident #21 the only true feed and could have put it differently. He reported the term feed wasn't respectful. Interview with CNA #22 on 06/03/25 at 11:18 A.M. confirmed she should have asked about the clothing protector for Resident #21 and had some kind of interaction with her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 4 of 32 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 06/10/2025 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 0557 Level of Harm - Minimal harm or potential for actual harm Review of the policy entitled Residents Rights date unknown revealed that the residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 5 of 32 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 06/10/2025 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 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Council Minutes, staff and resident interview, and policy review, the facility failed to ensure resident concerns were addressed in a timely manner or resolved. This affected three (#24, #35, #29) of three residents who attended a surveyor led Resident Council Meeting during the annual survey. The facility identified there were 13 residents who regularly attend resident council meetings. This had the potential to affect all of the residents who reside in the facility. The census was 46. Residents Affected - Some Findings included: Review of the Resident Council Minutes from 01/28/25 through 05/13/25 revealed the following concerns were documented on the Resident/Family Council Agenda/Minutes form: 01/28/25 call lights not answered in a timely manner. 02/11/25 residents would like a smoke time added daily at 7:00 P.M. and showers are cold on the A-wing 03/02/25 call lights still not being answered in a timely manner and would like administration to enforce the rules for the staff. 03/11/25 staff speaking rudely to residents, asking administration to start addressing complaints. 04/08/25 staff speaking rudely to residents 04/22/25 call lights not answered timely 05/13/25 call lights not answered timely Interview with Resident's #24 (President), #35 (Vice President) and #29 during a surveyor led Resident Council Meeting on 06/04/25 at 11:01 A.M. revealed they didn't feel like complaints were getting addressed in a timely manner by the administration. They revealed the request for an additional smoking break has been going on for months with no resolution. The call lights are not being answered in a timely manner which has been going on for months with no resolution. The shower room on the A-wing is still cold. They further complained about staff being rude to the residents which they have not seen any resolution for. They complained they have wanted to meet without staff present and for a resident to take the minutes of the meeting instead of the staff, but that has not been accommodated either. Interview with Activities Director (AD) #236 on 06/04/25 at 1:50 P.M. confirmed these areas of concern in resident council meetings are not being resolved in a timely manner because the residents are still complaining about them. She confirmed she knew the residents wanted to meet without staff, but a resident had to be trained to record the minutes and she had not been able to complete the resident training. Interview with the Administrator on 06/05/25 at 9:46 A.M. revealed she looked over the Resident/Family Council Agenda/Minutes after each meeting and confirmed the call lights were not resolved even though there were audits completed that proved otherwise. She revealed the staff and the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 6 of 32 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 06/10/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete who complained about the rudeness from the staff were interviewed and educated on how to treat the residents in a Town Hall Meeting, but there wasn't a concern form to be given to the surveyor. She confirmed the extra smoking time had not been resolved and neither had temperature in the shower in A-wing to the resident's satisfaction. She confirmed the Resident Council was a problem. Review of the policy entitled Resident Council dated 07/01/20 revealed the facility recognizes the residents' right to form and participate In group meetings while residing in the facility. The Resident Council Is a resident-oriented group designed for the residents to discuss nursing home standards, offer suggestions for practice guidelines affecting their care and treatment, quality of life, and review of resident rights. The life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. Any additional facility personnel will attend the meeting upon request of the residents. The Activity Director will attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council. Resident issues or concerns will be documented on the Resident/Family Concern Form and forwarded to the facility Administrator for the appropriate follow-up. Once the respective department has addressed the Resident/Family Concern and document the outcome the form is returned to the Life Enrichment Director to file with the Resident council Meeting Minutes. Event ID: Facility ID: 365365 If continuation sheet Page 7 of 32 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 06/10/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, resident council meeting, and facility policy review, the facility failed to ensure the residents were safe from abuse. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent assistance for eating, toileting, bed mobility, and transfers. He was always continent of bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed CNA #240 was trying to redirect Resident #24 back to his room. During a resident council meeting Resident #24 who was the President of the council on 06/04/25 at 11:01 A.M. revealed a Certified Nursing Aide (CNA) #240 called him an ass and he reported it to the Director of Nursing (DON) and she tried to smooth it over because the aide is dating her son who also works in the facility. A subsequent interview with Resident #24 on 06/04/25 at 3:51 P.M. revealed there was a resident who moved across the hall from him and for two nights the resident would moan and groan loudly and Resident #24 wasn't able to get any sleep. He told the CNA #240 she needed to get the resident moved to another room and the aide told him to quit being an ass. The resident stated he kicked CNA #240 out of his room. He stated the aide is rude to the residents and had several complaints on her from the residents. He stated the DON talked to him and tried to cover up the incident and said maybe the aide didn't mean anything by the comment she made and he told the DON to not cover for the aide. He revealed he was angry about the CNA calling him a name and he didn't pay money at the facility to be called names and felt it was abusive. He further revealed no one had asked him for a statement. Interview with CNA #240 on 06/04/25 at 2:31 P.M. revealed Resident #24 was being rude to her and she told the resident you don't have to be rude to me and admitted she called him an ass and changed the statement and said you don't need to be an ass. She reported she apologized to the resident about the statement and thought it was disrespectful to the resident. She reported it was a mistake on her part for the name she called him. Interview with the Administrator and DON on 06/04/25 at 2:58 P.M. revealed the Administrator didn't know anything about this incident. The DON said she was in the facility at the time of the incident and the resident was in the hall and he was being inappropriate with the CNA and the aide said to the resident don't talk to me that way and the resident continued and the CNA said something about treating people like an ass to the resident. The DON reported she took both of them aside and talked with them and they made amends. She reported the resident was inappropriate with staff and continued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 8 of 32 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 06/10/2025 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 0600 to have those behaviors. She reported she wanted to make sure her staff stays safe. Level of Harm - Minimal harm or potential for actual harm Review of the policy entitled Abuse, Neglect and Exploitation dated 07/11/24 revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Residents Affected - Few Verbal abuse-is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 9 of 32 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 06/10/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, Resident Council meeting, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state agency. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent assistance for eating, toileting, bed mobility, and transfers. He was always continent for bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed the CNA #240 was trying to redirect Resident #24 back to his room. During a resident council meeting Resident #24 who was the President of the council on 06/04/25 at 11:01 A.M. revealed a Certified Nursing Aide (CNA) #240 called him an ass and he reported it to the Director of Nursing (DON) and she tried to smooth it over because the aide is dating her son who also works in the facility. A subsequent interview with Resident #24 on 06/04/25 at 3:51 P.M. revealed there was a resident who moved across the hall from him and for two nights the resident would moan and groan loudly and Resident #24 wasn't able to get any sleep. He told the CNA #240 she needed to get the resident moved to another room and the aide told him to quit being an ass. The resident stated he kicked the CNA #240 out of his room. He stated the aide is rude to the residents and had several complaints on her from the residents. He stated the DON talked to him and tried to cover up the incident and said maybe the aide didn't mean anything by the comment she made and he told the DON to not cover for the aide. He revealed he was angry about the CNA calling him a name and he didn't pay money at the facility to be called names and felt it was abusive. He further revealed no one had asked him for a statement. Interview with CNA #240 on 06/04/25 at 2:31 P.M. revealed Resident #24 was being rude to her and she told the resident you don't have to be rude to me and admitted to she called him an ass and changed the statement and said you don't need to be an ass. She reported she apologized to the resident about the statement and thought it was disrespectful to the resident. She reported it was a mistake on her part for the name she called him. Interview with the Administrator and DON on 06/04/25 at 2:58 P.M. revealed the Administrator didn't know anything about this incident and it couldn't be reported to the state agency. The DON said she was in the facility at the time of the incident and the resident was in the hall and he was being inappropriate with the CNA and the aide said to the resident don't talk to me that way and the resident continued and the CNA said something about treating people like an ass to the resident. The DON reported she took both of them aside and talked with them and they made amends. She reported the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 10 of 32 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 06/10/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident was inappropriate with staff and continues to have those behaviors. She reported she wanted to make sure her staff stays safe. Review of the policy entitled Abuse, Neglect and Exploitation dated 07/11/24 revealed facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. Event ID: Facility ID: 365365 If continuation sheet Page 11 of 32 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 06/10/2025 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 0610 Respond appropriately to all alleged violations. 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, staff and resident interview, resident council meeting, and facility policy review, the facility failed to ensure an investigation was initiated for a allegation of abuse. This affected one (#24) of three residents reviewed for abuse. The census was 46. Residents Affected - Few Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent for eating, toileting, bed mobility, and transfers. He was always continent of bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed the CNA #240 was trying to redirect Resident #24 back to his room. During a resident council meeting on 06/04/25 at 11:01 A.M. Resident #24, who was the President of the council, revealed Certified Nursing Aide (CNA) #240 called him an ass and he reported it to the Director of Nursing (DON) and she tried to smooth it over because the CNA is dating her son who also works in the facility. A subsequent interview with Resident #24 on 06/04/25 at 3:51 P.M. revealed there was a resident who moved across the hall from him and for two nights the resident would moan and groan loudly and Resident #24 wasn't able to get any sleep. He told CNA #240 she needed to get the resident moved to another room and the aide told him to quit being an ass. The resident stated he kicked CNA #240 out of his room. He stated the aide is rude to the residents and had several complaints on her from the residents. He stated the Director of Nursing (DON) talked to him and tried to cover up the incident and said maybe the aide didn't mean anything by the comment she made and he told the DON to not cover for the aide. He revealed he was angry about the CNA calling him a name and he didn't pay money at the facility to be called names and felt it was abusive. He further revealed no one had asked him for a statement. Interview with CNA #240 on 06/04/25 at 2:31 P.M. revealed Resident #24 was being rude to her and she told the resident you don't have to be rude to me and admitted to she called him an ass and changed the statement and said you don't need to be an ass. She reported she apologized to the resident about the statement and thought it was disrespectful to the resident. She reported it was a mistake on her part for the name she called him. Interview with the Administrator and DON on 06/04/25 at 2:58 P.M. revealed the Administrator didn't know anything about this incident and did not initiate an investigation. The DON said she was in the facility at the time of the incident and the resident was in the hall and he was being inappropriate with the CNA and the aide said to the resident don't talk to me that way and the resident continued and the CNA said something about treating people like an ass to the resident. The DON reported she took both of them aside and talked with them and they made amends. She reported the resident was inappropriate with staff and continues to have those behaviors. She reported she wanted to make sure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 12 of 32 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 06/10/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her staff stays safe. She didn't have any interviews from staff or residents regarding the incident and didn't take a statement from the CNA or the resident. Review of the policy entitled Abuse, Neglect and Exploitation dated 07/11/24 revealed it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Event ID: Facility ID: 365365 If continuation sheet Page 13 of 32 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 06/10/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for residents who had hospice services. This affected two residents, (Residents #3 and #14) of two residents reviewed for hospice services. The facility census was 46. Findings Include: 1. Record review of Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 include dementia, anxiety, stage four kidney disease, heart disease, and shortness of breath. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for transfers and mobility. The resident received hospice services starting on 11/23/24. Review of Preadmission Screening and Resident Review (PASRR) records for Resident #3 revealed no PASRR was completed when hospice services were initiated for the resident. 2. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 include dementia, anxiety disorder, dysphagia, repeated falls, malnutrition, anemia, muscle weakness, and osteoporosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living skills, except the resident required assistance with feeding. Resident #14 had orders for hospice services beginning on 12/17/24. Review of Preadmission Screening and Resident Review (PASRR) records for Resident #3 revealed no PASRR was completed when hospice services were initiated for the resident. Interview on 06/09/25 at 10:52 A.M. with Social Service Designee, (SSD) # 333 verified there were no additional PASRR records for Resident #3 or Resident #14, and neither resident had a PASRR completed when the resident had a significant change was was admitted to hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 14 of 32 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 06/10/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, review of the care conferences and facility policy review, the facility failed to ensure residents received routine care conferences. This affected two (#29 and #39) of three residents reviewed for care conferences. The census was 46. Findings included: 1. Medical record review for Resident #29 revealed an admission date of 11/04/18. Medical diagnoses included coronary artery disease, heart failure, hypertension, and diabetes. Review of the care conferences for Resident #29 revealed there were documented care conferences on 10/10/24 and on 02/27/25. Review of the quarterly MDS dated [DATE] revealed Resident #29 was cognitively intact. Interview with the Resident #29 on 06/03/25 at 11:25 A.M. revealed she had not had a care conference every three months. Interview with Social Services Designee (SWD) #214 on 06/05/25 at 10:01 A.M. revealed she was supposed to complete care conferences every three months and she was running behind. 2. Medical record review for Resident #39 revealed an admission date of 10/26/23. Medical diagnoses included heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency. Review of the care conferences revealed Resident #39's last care conference was on 10/17/24. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Interview with Resident #39 on 06/03/25 at 12:03 P.M. reported she didn't remember having a care conference every three months. Interview with Social Services Designee (SSD) #214 on 06/04/25 at 10:01 A.M. confirmed she was supposed to complete care conferences every three months and she was behind. Review of the policy entitled Comprehensive Care Planning Policy dated 03/20/25 revealed the care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with Resident Assessment Instrument (RAI) requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 15 of 32 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 06/10/2025 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 observation, medical record review, and staff interview, the facility failed to ensure a safe homelike environment was free on unsecured potential poisonous chemicals. This affected one (#37) of 46 residents observed in the facility for potential hazards. The facility census was 46. Findings included: Observations on 06/02/25 through 06/04/25 from 9:45 A.M. to 3:30 P.M., revealed the following environmental issues. The shower room closet located in the short A unit hallway had a closure which was easily unlocked and had a bottle labeled disincentive chemical cleaner. The warning label stated to keep out of the reach of children. In the unlocked B hall unit shower room, there was a gallon size container, with a nozzle sprayer and tubing attached, on the floor. It contained a clear liquid. There was no label on the container to identify the liquid. Observations from 06/09/25 from 9:45 A.M through 3:30 P.M. revealed Resident #37 wandering in hallways, rooms and common areas, including the A and B units hallways. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident # 37 included dementia, insomnia, and cognitive communication deficit. The resident wore a monitor device for elopement monitoring. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and ambulated without assistance devices. Interview on 06/05/25 at 7:30 A.M., the Maintenance Director, (MD) # 202 verified the unlocked closet with chemical and unlabeled gallon sprayer in the unlocked unit B shower room. He stated all chemicals should be stored with a locks a resident could not open. He stated he could not identify the clear liquid as it was unlabeled, and all containers must be labeled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 16 of 32 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 06/10/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, the facility failed to ensure a restricted liquid diet was honored. This affected one (#39) of two reviewed for hydration during the annual survey. The census was 46. Residents Affected - Few Findings include: Medical record review for Resident #39 revealed an admission date of 10/26/23. Medical diagnoses included heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was independent for eating, toileting, bed mobility, and setup or clean-up assistance for transfers. She was always continent for bowel and bladder. Review of the physician's order dated 04/30/25 revealed Resident #39 was on a fluid restriction to give 1200 cubic centimeters (cc) for a 24-hour period. Dietary to give 840 cc's total, for breakfast 360 cc's, for lunch 240 cc's, and dinner 240 cc's. Observation of Resident #39's lunch tray on 06/03/25 at 12:00 P.M. revealed she had 240 cc's of water and 240 cc's of iced tea for a total of 480 cc's. Further observation of a breakfast tray on 06/05/25 revealed she had 240 cc's of milk, 240 cc's of coffee and 120 cc's of orange juice for a total of 600 cc's. Interview with Resident #39 on 06/03/25 at 12:12 P.M. revealed she was on a fluid restriction and sometimes the meals have too many fluids on them for consumption. Interview with the Dietary [NAME] (DC) #250 on 06/05/25 at 7:33 A.M. confirmed Resident #39 was on a fluid restriction and she confirmed she placed 600 cc's of fluids on her breakfast tray and should have only put 360 cc's on the tray for consumption. Interview with Registered Nurse (RN) #204 on 06/09/25 at 10:45 A.M. revealed there are times Resident #39 gets too much to drink on her meal trays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 17 of 32 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 06/10/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to have a medication error rate less than five percent. This affected two residents (#15 and #43) of three residents observed for medication administration. The facility census was 46. Residents Affected - Some Findings Included: Observation on 06/04/25 of medication pass revealed 30 opportunities were observed with two errors for a medication error rate of 6.67%. 1. Review of medical records for Resident #43 revealed an admission date 07/18/24. Diagnoses included chronic obstructive pulmonary disease, osteoporosis, pneumonia, paroxysmal atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 had Brief Interview of Mental Status (BIMS) score of 15 that indicated he was cognitively intact. Review of the plan of care dated 11/25/23 revealed that Resident #43 had problems with elimination and bowel constipation related to use of pain medications. Interventions included encourage fluids, administration medication as ordered, and diet as ordered. Review of physician order dated 12/20/24 revealed Resident #43 had an order for Sennoside 8.6 milligram (mg) give two tablets for constipation twice a day. Observation on 06/04/25 at 7:37 A.M. of medication pass with Licensed Pratical (LPN) #257 who prepared medication for Resident #43. LPN #257 prepared and administered Senna Plus 8.6-50 mg two tablets to Resident #43 with his morning medication. Interview on 06/04/25 at 1:00 P.M. with LPN #257 it was verified that she did give Resident #43 the wrong medication of Senna Plus 8.6-50 mg instead of Sennoside 8.6 mg the resident had ordered. 2. Review of medical record for Resident #15 revealed an admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of quarterly MDS dated [DATE] revealed a BIMS score of one indicating the resident was severely cognitively impaired. Review of physician order dated 09/22/24 revealed Resident #15 had an order for Potassium Chloride extended release (ER) (electrolyte supplement) 20 milliequivalent (MEQ) one tablet once a day. Observation on 06/04/25 at 8:00 A.M. with Registered Nurse (RN) #204 who was preparing medication for next Resident #15 revealed the RN prepared and administered Amiodarone 200 mg, Calciumn (supplement) 600 mg with Vitamin D 3, Citalopram (antidepressant) 20 mg, Depakote Sodium (anticonvulsant used for mood stabalization) 125 mg, Eliquis (blood thinner)5 mg, Lasix (diuretic) 40 mg, Gabapentin (anticonvulsant) 200 mg, Lansoprazole (proton pump inhibitor) 30 mg, Metoprolol (used to treat high blood pressure) 25 mg, Senna-Plus (laxative) 8.6-50 mg, and Potassium 20 Milliequivalent and crushed all medication. RN #204 placed all medication powder into applesauce. RN #204 headed to Resident #15 room, then verified she crushed all of Resident #15 medication. RN #204 gave Resident #15 her crushed medication including Potassium Chloride 20 ER MEQ. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 18 of 32 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 06/10/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/04/25 at 1:19 P.M. with RN #204 who verified that Resident #15 who had Potassium Chloride ER 20 MEQ crushed and placed in applesauce and administered to the resident. Review of the facility policy titled General Dose Preparation and Medication Administration date 11/15/24 revealed prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy. The facility should not leave medications or chemicals unattended. Facility staff should avoid touching the medications with bare hands when opening a bottle or unit dose package. Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Event ID: Facility ID: 365365 If continuation sheet Page 19 of 32 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 06/10/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record, observation, interview, pharmacy interview, policy, the facility failed to provide safe delivery of medication by crushing potassium 20 Milliequivalent for one resident (#15) out of residents reviewed on annual. The facility census was 46. Residents Affected - Few Findings Included: Review of record revealed that Resident #15 had admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of Quarter MDS dated [DATE] revealed that BIMS was 1 that indicated she was severely cognitively impaired. Review of plan of care dated 08/21/24 revealed that Resident #15 had a risk for cardiac that had arteriosclerotic heart disease. Intervention was to provide small meals or frequent rather than three large meals, encourage activity level, and administer medications as ordered. Review of physician order dated 08/21/24 revealed that Resident #15 had an order to crush medications unless contraindicated. Review of physician order dated 09/22/24 revealed that Resident #15 had an order for Potassium Chloride extended release 20 milliequivalent one tablet once a day. Observation on 06/04/25 at 8:00 A.M. with Registered Nurse (RN) #204 who was preparing medication for next Resident #15. RN #204 took all medication including Amiodarone 200 mg, Calcium 600 mg with Vitamin D 3, Citalopram 20 mg, Depakote Sodium 125 mg, Eliquis 5 mg, Lasix 40 mg, Gabapentin 200 mg, Lansoprazole 30 mg, Metoprolol 25 mg, Senna-Plus 8.6-50 mg, and Potassium 20 Milliequivalent (MEQ) and crushed all medication. Interview on 06/04/25 at 1:19 P.M. with RN #204 who verified that Resident #15 who had Potassium extended release 20 Milliequivalent (MEQ) and placed in applesauce and gave her. Interview on 06/04/25 at 2:31 P.M. with Pharmacist #399 who stated that you are never to crush potassium chloride 20 MEQ with a pill form that was extended release. Review of the facility document titled Common Oral Dosage Forms That Should Not Be Crushed dated year 2023 revealed that Potassium K tablet extended release was not to be crushed. Review of the facility policy titled General Dose Preparation and Medication Administration date 11/15/24 revealed that the prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy. The facility should not leave medications or chemicals unattended. Facility staff should avoid touching the medications with bare hands when opening a bottle or unit dose package. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 20 of 32 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 06/10/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and facility policy review, the facility failed to ensure medications were not expired and the facility failed to provide safe storage and delivery of medication for one resident (#28). The facility census was 46. Findings Included: Observation on [DATE] at 8:40 A.M. of the overstock medication room, revealed there were seven bottles of Folic Acid 400 micrograms (mcg) with an expiration date was 02/2025. Interview on [DATE] at 8:40 A.M. with Registered Nurse (RN) #204 it was verified the seven bottles of Folic Acid 400 mcg expired 02/2025. Each bottle was unopened and contained 250 tablets. Review of the facility document titled In House Stock dated unknown revealed that the facility did have Folic Acid 400 micrograms (mcg) over the counter for stock. Review of the facility policy titled Storage and Expiration Dating of Medications and Biological's dated [DATE] revealed the facility should ensure medications and biological's are stored in an orderly manner in cabinets, drawers, carts, refrigerators, and freezers of sufficient size to prevent crowding. The facility should destroy or return all discontinued, outdated or expired, or deteriorated medications or biological's in accordance with pharmacy return/destruction guidelines and other applicable laws, and in accordance with the policy. 2. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #28 include diabetes, cerebral infarction, edema, symbolic dysfunctions, and hypertension. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was independent in Activities of Daily Livings (ADL) skills. The resident had physician orders for oral Hydralazine (used to treat high blood pressure)50 milligrams three times a day at 3:00 A.M. - 5:00 A.M., 1:00 P.M.- 4:00 P.M. , and 7:00 P.M. - 11:00 P.M. for hypertension . Review of the [DATE] Medication Administration Record, (MAR) revealed Resident #28 received Hydralazine 50 milligrams signed by Registered Nurse, (RN) #241. Observation on [DATE] at 9:45 A.M. of Resident #28's room revealed the resident was not in the room and there was pink/orange pill inside the pill cup on the bedside table of Resident #28. Interview on [DATE] at 9:46 A.M. with RN #204 verified there was a pill cup with a pink/orange pill on the bedside stand of Resident #28. RN #204 identified the pill as Hydralazine and verified the medication should have been given on [DATE] at 3:00 A.M. -5:00 A.M. of by the night shift nurse. Review of the June MAR with RN #204 verified the dose was documented as administered by the night shift nurse. RN #204 verified when administering medications the nurse must observe the resident taking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 21 of 32 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 06/10/2025 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 0761 the medication and not to leave the medication at the bedside. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 10:30 A.M. Resident #28 revealed she is not always watched by the evening nurse when she takes her medications as sometimes she is sleepy and the medication is left on the bedside table by the nurse. Resident #28 verified the pill was in the pill cup this morning when she woke up. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 22 of 32 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 06/10/2025 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 0791 Provide or obtain dental services for each resident. 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, staff and resident interview and facility policy review, the facility failed to ensure a follow-up appointment was made for a resident who had a tooth that was broke off at the gum line. This affected one (#29) of four residents reviewed for dental services during the annual survey. The census was 46. Residents Affected - Few Findings included: Medical record review for Resident #29 revealed an admission date of 11/04/18. Medical diagnoses included a stroke, coronary artery disease, heart failure, hypertension, and diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact. She was independent for eating, toileting, bed mobility and she required a Hoyer lift for transfers. She was always incontinent for bowel and bladder. Review of the resident's dental appointment dated 09/09/24 revealed the dentist tried to extract her tooth and the root was under the gum line and it wouldn't come out. He spoke to Social Services Designee (SSD) and Director of Nursing (DON) about the appointment and the new treatment plan. There was an extraction needed for this tooth to remove the root and a referral was inserted into the chart. Review of an oral surgical referral dated 09/12/24 revealed Resident #29 had residual root tips that needed to be removed. Review of the notes for Resident #29 dated 09/20/24 revealed she had an infection of the left lateral lower retained tooth post prior partial removal. Amoxicillin was ordered for ten days and administered. The resident was to follow-up with dentistry. Interview with Resident #29 on 06/03/25 at 11:31 A.M. revealed she had an appointment last year sometime to get a tooth pulled and was supposed to have another appointment to get the root pulled out and hasn't heard back from the staff about the appointment. She stated she uses oragel if needed if the tooth bothers her. She denied she was in pain with the tooth. Interview with the Appointment Scheduler (AS) #200 on 06/09/25 at 9:44 A.M. revealed she called the surgical dentist clinic to schedule an appointment for the resident, but left a message because the recording says if they choose you to get your tooth fixed, they will call you and if not you won't hear back from the clinic. She reported the resident was on Medicaid and the surgery clinic was the only clinic that will take Medicaid residents. Review of the policy entitled Dental Services dated 04/02/24 revealed the facility will assist residents in obtaining routine and 24-hour emergency dental care/services to meet the needs of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 23 of 32 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 06/10/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, staff interviews and facility policy review, the facility failed to prepared palatable food. This affected 29 residents, (#20, #39, #35, #5, #28, #2, #34, #12, #33, #198, #38, #8, #17, #27, #43, #29, #3, #13, #32, #198, #22, #10, #26, #31, #25, #24, #7, #23, and #37) who were served regular consistency textured diets. The facility census was 46. Residents Affected - Some Findings Include: Review of medical records revealed the following residents had a physician order for a regular consistency textured diet, Resident #20, #39, #35, #5, #28, #2, #34, #12, #33, #198, #38, #8, #17, #27, #43, #29, #3, #13, #32, #198, #22, #10, #26, #31, #25, #24, #7, #23, and #37. Observation on 06/02/25 at 11:46 A.M. revealed Residents #11, #2, and #24 received popcorn shrimp at the lunch meal in the dining room. The shrimp had a white coating and was not browned. The residents appeared to have difficulty chewing the exterior coating. Observation on 06/02/25 at 12:06 P.M. Resident #29 received her lunch meal tray in her room. The plate contained popcorn shrimp. The shrimp had a white coating and appeared hard. Resident took bites of the shrimp and took it out of her mouth. Interview on 06/02/25 at 11:47 A. M. with Residents #11, #2 and #24 revealed the shrimp was unappetizing, difficult to chew and they could not eat the shrimp. Interview on 06/02/25 at 12:06 P.M. with Resident #29 revealed she could not chew or soften the shrimp coating to swallow it. Interview on 06/04/25 at 11:17 A.M. the Registered Dietitian #400 verified the shrimp served on 06/02/25 at lunch was not an oven ready product. It should have had a golden brown appearance and a coating that was easily chewed. Interview on 06/04/25 at 12:43 P.M. with [NAME] #250 it was verified on 06/02/25 she prepared the popcorn shrimp in the oven and stated the shrimp should have been prepared in a deep fryer. [NAME] #250 stated the facility did not have a deep fryer. [NAME] #250 verified the shrimp remained white and the coating became harder in the oven. Review of facility policy, Food Production and Safety , dated 01/05/23 revealed foods are prepared by methods to maintain, develop and enhance flavor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 24 of 32 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 06/10/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to prepare food in a sanitary manner. This affected 45 residents who received food from the kitchen. The facility census was 46. Findings Include: 1. Observation on 06/02/25 at 10:05 A.M. of Diet Manger, (DM) #208 revealed white flakes of skin surrounded with bright reddened ring of skin on bilateral underside of forearms, measuring approximately four inches by two inches. When DM #208 touched the skin areas, flaky skin was removed. Interview on 06/02/25 at 10:05 A.M. with DM #208 verified the skin areas were diagnosed as a noncommunicable skin condition. DM #208 verified the skin areas should be covered due to the flaky skin. DM #208 verified her job duties include food preparation, food service and dishwashing/sanitizing. Observation on 06/04/25 at 11:17 A.M. of DM #208 revealed the skin areas on her bilateral forearms were exposed with no protective covering and the staff was observed at the three compartment sink washing/sanitizing dishes. DM #208 was also observed to assist with the preparation of puree food items. Interview on 06/04/25 at 11:17 A.M. with DM #208 verified she did not have protective covering on her exposed skin areas on the bilateral forearms. She stated the kitchen was hot, but she would don a jacket to cover the skin areas. Observation on 06/04/25 at 11:39 A.M. revealed DM #208 had donned a jacket with long sleeves. DM #208 was observed to wash/sanitize dishes in the three compartment sink, however the sleeves of the jacket were pushed up and the skin areas remained exposed. Interview on 06/04/25 at 11:39 A.M. with DM #208 verified the sleeves of the jacket were pushed up and the skin areas remained exposed while she used the three compartment sink to wash/sanitize the dishes. Review of facility policy, Food and Nutrition, Personnel and Training, dated 03/28/25 revealed food employees report to work in clean/safe attire. Ohio Administrative Code 3717-1 -01 A, states food employees are to keep their hands and exposed portions of their arms clean. Workers with psoriasis should consider wearing protective coverings when handling food minimize the risk of skin flakes contaminating food. 2. Observation on 06/04/25 at 11:17 A.M., revealed [NAME] #250 was preparing the pureed foods with a food processor. [NAME] #250 was noted to rub her forehead with her bare hand and arm, partially exposing her hair from under the hairnet during the puree process. Between pureeing the meat mixture and then pureeing the tomatoes, [NAME] #250 washed the blender bowl in the three compartment sink. [NAME] #250 immediately reassembled the food processor by placing the bowl blade into the bowl with her bare hands. The bowl was observed to contain rinse water from the three compartment sink which covered the bottom of the bowl. Interview on 06/04/25 at 12:02 P.M. [NAME] #250 verified she reassemble the blender bowl blade in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 25 of 32 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 06/10/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the bowl with her bare hands and did not ensure the water was removed from the bowl prior to processing the next food item. [NAME] #250 verified she rubbed her head with her bare hand and did not then sanitize her hands. [NAME] # 250 also confirmed when she used her bare hand to rub her face it dislodged hair from her hair net. Review of facility policy, Food and Nutrition, Sanitation and Infection Control, dated 06/01/18 revealed when handling cleaned and sanitized equipment, staff will avoid touching the parts that will come in contact with the food. Review of facility policy, Food and Nutrition, Personnel and Training, dated 03/28/25 revealed food employees wear a hair restraint which will cover all hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 26 of 32 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 06/10/2025 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** Based on observation, medical record review, staff interview, and facility policy review the facility failed to ensure facility staff performed hand hygiene. This affected one resident (#15) observed during medication pass and additionally affected three residents (#98, #5, and #99) who had their meal trays delivered by staff without hand hygiene being performed. The census was 46. Residents Affected - Some Findings included: 1. Review of Resident #15's medical record revealed an admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a one on the Brief Interview of Mental Status indicating the resident had severe cognitive impairment. Review of physician orders revealed the resident had the following medication orders: Lasix (diuretic) 40 milligrams (mg) take one tablet twice a day dated 08/21/24, Senna plus (laxative) 8.6-50 mg take two tablets twice a day dated 08/24/24, and Eliquis (anticoagulant) 5 mg one tablet take twice a day dated 01/09/25. Observation of medication pass for Resident #15 on 06/04/25 at 8:00 A.M. with Registered Nurse (RN) #204 revealed as the medications were prepared RN # 204 dropped the Lasix, Eliquis and the Senna plus on the top of the medication cart, and used her bare, ungloved hand to pick up the medication and put the medication in the medication cup with the rest of the morning medication for Resident #15. RN #204 proceeded to crush all of Resident #15's medications, place them in applesauce and administer the medications to the resident. Interview on 06/04/25 at 8:15 A.M. with RN #204 it was verified she had dropped the Lasix 40 mg, Eliquis 5 mg, and Senna plus 8.6-50 mg on top of her medication cart that was not clean and used her bare, ungloved fingers to pick up the medications and put the medication in the cup, crushed the medication and administered the medications to Resident #15. 2. Observation on 06/04/25 at 12:29 P.M. Dietary Manger, (DM) #208 was observed to pass lunch meal trays to three residents in three separate residents (#98, #5, and #99). DM #208 did not perform hand hygiene between resident tray passes. DM #208 was observed to enter each room, remove the food lid on the tray, set the lid down in the room, touching items on the tray and the food delivery cart. DM #208 then exited the individual resident room walking past a hand sanitizer dispenser which is mounted on the wall in each resident room. DM #208 was observed to pass the three trays to Resident #98, #5, and #99 without performing hand hygiene. Interview on 06/04/25 at 12:29 P.M. DM #208 verified she did not wash her hands or use hand sanitizer between each resident meal tray delivery. She stated she knew better and should have used hand sanitizer between each meal tray delivery. She stated she did not often deliver trays to the residents. Review of facility policy, Hand Hygiene, dated 02/28/25 revealed employees are to use alcohol based rub or hand wash after touching a patient's environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 27 of 32 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 06/10/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation of Resident #29's room on 06/03/25 at 11:26 A.M., revealed the toilet was dirty and had a metal piece on the back of the toilet to hold the seat in place that had built up yellowish gray substance on it. The handwashing sink was rusted, there was tape holding the light cover in place behind her bed, the floor was dirty and sticky and the corners of the floor had a build up gray substance in the corners. Interview with Resident #29 on 06/03/25 at 11:28 A.M., revealed she didn't like her floors looking the way they do and didn't like her toilet and sink with the rust and thought they were dirty. 4. Observation of Resident #39's room on 06/03/25 at 12:26 P.M., revealed the wires to her bed control were disconnected and the resident wasn't able to control the bed movement, the floor was sticky, the light above the Handwashing sink was burned out and the light cover was a dark yellow. Around the toilet and the floor in the bathroom was a dark gray substance and the caulking around the toilet was supposed to be white but it turned to a dark grayish color. 5. Observation of Resident #8's room on 06/03/25 at 3:14 P.M., revealed the sink was rusted, the light over the sink was yellowed to the point the light didn't get bright, there were gray stains on the bathroom floor tile, back of the toilet had a metal piece holding the toilet seat to the toilet revealed it had gray substance on it, and there were gouges on the doorway coming out of the bathroom. 6. Observation of Resident #3's room on 06/03/25 at 2:05 P.M., revealed the corners on the floor had a built up gray substance in them, there were gouges out of the walls next to her bed, the call light was taped at the connector, the bathroom floor had gray stains on it and around the bottom of the toilet was yellowed, furniture had gouges out of it and scraps on the dresser, she wasn't able to turn on her light from the bed because the string was too short, there is built up dirt on the lights and dusty bulbs. 7. Observation of Resident #37's room on 06/03/25 at 2:57 P.M., revealed the toilet seat and around the bottom of the toilet was yellowed. The floor was sticky. Observation and interview on 06/05/25 from 8:28 A.M. to 8:41 A.M., with the Maintenance Director (MD) #202, confirmed all of the above mentioned areas were in need of repair. He revealed he had no help and did the best he could. Based on observation, medical record review, staff interview, resident interview, resident council minutes review, maintenance work order review, and policy review, the faciity failed to provide an homelike environment. This affected nine residents (#3, #7, #8, #14, #29, #37, #38, #39, and #198) directly and affected all 26 residents on the A Unit of 46 resident rooms observed for environment. The facility census was 46. Findings included: 1. Review of record for Resident #38 revealed she was admitted on [DATE]. Diagnoses included hypertension, acute respiratory failure, chronic obstructive pulmonary disease, and oxygen dependent. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was alert and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 28 of 32 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 06/10/2025 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 0921 oriented. Level of Harm - Minimal harm or potential for actual harm Review of the facility document work order date 05/01/25 revealed that Resident #38 had an order to fix her broken air conditioner. Residents Affected - Some Interview on 06/03/25 at 3:05 P.M., with Resident #38 who stated that her room air conditioner had been out for a month. Resident #38 stated Maintenance Director (MD)#202 had informed her that he would order parts to be fixed. Resident #38 stated she has not seen MD #202 since. Resident #38 stated she was on oxygen and liked it cooler in her room. Observation on 06/03/25 at 3:05 P.M. room was warm, with a fan blowing on her to cool her. Resident #38 skin was warm to touch. Interview on 06/04/25 at 3:45 P.M., MD #202 verified that Resident #38 had not had her air conditioner fixed for two months, because there was an old air conditioner unit in Resident #38 room. Maintenance #202 stated he did not find any parts to be replaced for the old unit. 2. Review of record for Resident #198 revealed she was admitted on [DATE]. Diagnoses included acute and chronic systolic and diastolic heart failure, hypertension, and chronic obstructive respiratory failure with hypoxia. Review of Quarter MDS dated [DATE] revealed that Resident #198 was alert and oriented. Review of the facility document work order date 05/01/25 revealed that Resident #198 had an order to fix her broken air conditioner. Observation on 06/03/25 at 3:50 P.M., with Resident #198 who was sitting in her recliner. Resident #198's room was warm. Resident #198 was sitting watching television with a box fan blowing on her while on 4 liters of oxygen. Resident #198 was flushed and sweaty. Interview on 06/03/25 at 3:55 P.M., with MD #202 verified that Resident #198 also had no air conditioner in her room. Maintenance #202 stated the parts were unable to be found to repair the unit. 8. Review of Resident Council Meeting dated 01/28/25 and 03/19/25 revealed the residents reported low temperatures in the shower rooms. Resident Council Meeting minutes dated 02/11/25 and 03/19/25 revealed residents reported the A unit shower room was cold. Observation on 06/09/25 at 9:06 A.M. with Maintenance Director (MD) #202 revealed the room temperature near the entrance door to the shower room was 69 degrees Fahrenheit. The ceiling exhaust fan was on and there was a draft from under the door, across the shower area to the exhaust fan. There were four ceiling intake fans and louvers with a heavy build up of gray debris resembling dust and dirt above the resident shower and dressing areas. When turning on the switch to the wall heater, the unit did not come on. Interview on 06/09/25 at 9:06 A.M., MD #202 verified the shower room temperature should be 71 to 81 degrees Fahrenheit, and /or what residents feel is comfortable. He stated the fans and louvers needed cleaned and verified the wall heater did not work. He verified a draft from the floor to the ceiling in the shower area. He verified the residents had reported the A unit shower room was cold. 9. Review of the Resident Council Meeting minutes dated 05/13/25 revealed residents reported the rooms were not getting cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 29 of 32 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 06/10/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of A unit door entry floors to all resident rooms, (Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) had a blacked build up at the threshold strip juncture with the hallway. There was a blackened buildup at the doorway and corners in the rooms. Interview on 06/05/25 at 7:30 A.M., the MD #202 verified the blacked area at every room on the A unit floor at the entry way and in rooms corners. The MD #202 stated the A unit had not been renovated and there was no written planned program for the completion of the floor replacement or cleaning. 10. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 include dementia, anxiety disorder, dysphagia, repeated falls, malnutrition, anemia, muscle weakness, and osteoporosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living skills. Observation on 06/02/25 at 9:50 A.M., revealed Resident #14's bed up against the wall on the right side. There was a strip of wallpaper approximately 45 inches wide and six feet long missing from the wall, exposing a rough surface. Interview on 06/05/25 at 7:30 A.M., the MD # 202 verified Resident #14 had missing wallpaper with a rough surface. He verified Resident #14 laid up near the wall. MD #202 stated he was not notified of the missing wallpaper. 11. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident # 37 included dementia, insomnia, and cognitive communication deficit. The resident wore a monitor device for elopement monitoring. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and ambulated without assistance devices. Review of the Resident Council Meeting minutes dated 03/11/25 revealed residents reported the chairs needed repaired. Observation on 06/03/25 at 11:12 A.M., of the dining room chairs revealed one chair of ten in the main dining room, had the left arm not adhered to the chair. The arm of the chair could easily be removed from the connecting joint when pulled up. Ten of the ten chairs had worn wooded arms with the water sealing finished removed, leaving a penetrable surface in the wood grain. Interview on 06/02/25 of Certified Nursing Assistant (CNA) #206 verified the dining chair was broken and set it along the wall in the dining room. He verified the wooden arms of all the dining chairs were worn and had the protective surfaces removed. Observation on 06/04/25 at 10:002 A.M., the identified dining room chair remained in use in the dining room by Resident #37. Interview on 06/05/25 at 7:30 A.M., the MD #202 verified the identified dining room chair remaining in the dining room and the arm of the chair was broken. MD #202 verified a resident sitting in the chair could easily pull the arm up and the chair be destabilized. MD #202 verified all the dining room chairs had exposed wooden penetrable surfaces on the chair arms. MD #202 stated the broken chair was not reported to him and taken out of service. He stated setting the chair aside in the dining (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 30 of 32 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 06/10/2025 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 0921 room was not putting the chair out of service. Level of Harm - Minimal harm or potential for actual harm Review of facility policy, Routine Environmental Cleaning, dated 06/28/24, revealed proper cleaning of environmental surfaces is necessary to break the chain of infection. Residents Affected - Some This deficiency represents non-compliance investigated under Complaint Numbers OH00163527 and OH00162529. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 31 of 32 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 06/10/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident interview, family member interview, and staff interview, the facility failed to ensure a resident was provided a pest free environment. This affected one (#11) of 46 resident rooms observed for pest. The facility census was 46. Residents Affected - Few Findings include: Record review of Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident #11 include cerebral infarction, muscle weakness, dysphagia, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for dressing and transfers. Observation on 06/02/25 at 10:05 A.M., revealed the Resident #11 in room B 23. On 06/03/25, Resident #11 was moved into room B 21. Observation on 06/03/25 at 8:30 A.M. revealed 10 to 20 quarter length black insects with wings on the floor in Resident #11 previous room, room B23. There were no insects observed in the B 23 room on 06/02/25. Interview on 06/03/25 at 8:30 A.M., Resident #11 revealed she had a swarm of flying ants coming out of the ceiling near her window six feet from her bed, in the past day. She stated she was afraid the ants would get in her mouth when she slept. Interview on 06/03/25 at 8:35 A.M. , with Certified Nursing Assistant, (CNA) #22 verified the winged insects on the floor in B 23 and verified Resident #11 had been moved on 06/02/25 evening shift due to the flying insects. Interview on 06/04/25 at 7:10 A.M., with Resident #11 family representative stated when she visited a week ago, she had seen her mother with the bugs on her. She had to remove the insects off of Resident #11. Resident #11 family representative stated the resident had weakness to one side, and was unable to get them off herself. Resident #11 family representative stated she was upset because the facility did not manage pests in her mother's room. Interview on 06/05/25 at 7:30 A.M., with the Maintenance Director (MD) #202 verified Resident #11 had flying insects in her room on 06/02/25 and was moved due to the resident's request. He stated he was aware of the insects on 06/02/25 and contacted the pest control, which had not arrived to exterminate as of 06/05/025. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365365 If continuation sheet Page 32 of 32