Health inspection·October 24, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation was conducted on 10/23/19 at 3:10 P.M. of Resident #20 propelling self down hallway in wheelchair with large amount of incontinence of urine going down both legs of her pants and strong urine smell. Observation was conducted on 10/24/19 at 8:25 A.M. of Resident #20 and revealed Resident #20's bedside commode was directly in view of the hallway inside of her room. Resident #20 was observed attempting to toilet herself on her bedside commode with the door open. Interview was conducted on 10/22/19 at 1:45 P.M. with State Tested Nursing Assistant (STNA) #34 and she stated that Resident #20 will not keep any attend on and will throw them in the corner. She stated Resident #20 uses a bedside commode but will still urinate all over the floor and they placed the bedside commode in front of the bathroom door because she was urinating all over the bathroom floor that other residents use. Interview was conducted on 10/23/19 at 9:35 A.M. with STNA #16 and she stated Resident #20 will take herself to the bathroom and will not leave pull ups on and they have to change her at least once a day. She stated she does have a bedside commode and will urinate on floor in front of it and all over her room. Interview was conducted on 10/23/19 at 3:21 P.M. with Licensed Practical Nurse (LPN) #30 and she verified large amount of incontinence of urine visible for Resident #20 as well as previous dried urine stains on pants from earlier incontinent episode. Interview was conducted on 10/24/19 at 8:25 A.M. with Registered Nurse (RN) #96 and she verified Resident #20 had her pants pulled down and was attempting to toilet herself with the door open and the bedside commode in the doorway. Review of facilities Resident Rights and Facility Responsibilities Policy dated November 2016 revealed the facility must treat each resident with dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of quality of life and protect and promote the rights of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 2 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of the Ohio Revised Code and policy review, the facility failed to maintain proper documentation of residents advanced directive wishes for their code statuses on valid forms. This affected two (#63 and #89) of two residents reviewed for advanced directives. The resident census was 88. Findings include: 1. Record review of Resident #89's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, insomnia, hypocalcemia, dementia with behavioral disturbance, muscle weakness, dissociative conversion disorder, epilepsy anemia, other nail disorder and dysphagia. Review of Resident #89's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #89 also required supervision with eating on the 09/30/19 MDS. Review of Resident #89's electronic medical record revealed resident was listed to have a Do Not Resuscitate Comfort Care Arrest (DNRCCA) order in the electronic chart. Review of Resident #89's paper chart revealed a red paper in the chart that stated resident was a do not resuscitate comfort care (DNRCC). Resident #89 also had a generic hospital form indicating resident was a DNRCCA signed by the physician at the hospital on [DATE]. Further review of Resident #89's chart revealed resident to have an appendix A form that indicated his code status to be a full resuscitation effort arrest dated 12/08/09. Interview with the Director of Nursing (DON) on 10/21/19 at 2:58 P.M. verified Resident #89 to be listed as a DNRCCA in the electronic chart. The DON confirmed Resident #89 did not have an appendix A form signed to indicate Resident #89 was a DNRCCA. The DON also verified Resident #89 had an official full resuscitation effort arrest and a red paper indicating resident was a DNRCC in the chart. 2. Record review of Resident #63's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; other abnormalities of gait and mobility, muscle weakness, central retinal vein occlusion, other malaise, unspecified dementia with behavioral disturbance and anxiety disorder. Review of Resident #63's quarterly MDS assessment dated [DATE] revealed resident to be severely cognitively impaired and required supervision with eating, bed mobility, transfers, dressing, toileting and personal hygiene. Review of Resident #63's electronic medical record revealed resident was listed to have a Do Not Resuscitate Comfort Care (DNRCC) order in the electronic chart. Review of Resident #63's paper chart revealed resident to have an appendix A form that indicated her code status was a DNRCC. Further review of Resident #63's appendix A code status form revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 3 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0578 form was not signed by the physician. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 10/21/19 at 2:58 P.M. verified Resident #63's code status appendix A form indicating resident had a DNRCC code status was not signed by the physician. Residents Affected - Few A review was conducted on the code status documents on the Ohio Revised Code 3701-62-04 required the facility to document the Resident's code status on the approved Appendix A form. Review of the facility's undated Advanced Directives policy revealed a copy of the valid advanced directive must be included in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 4 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to notify the physician and family when a resident had a fall. This affected one resident (Resident #79) of three residents reviewed for falls. Facility census was 88. Findings Include: Review of Resident #79's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteoporosis with history of pathological fracture, anxiety, depression, emphysema, history of cerebral infarction, and endometrium cancer. Review of the medical record for Resident #79 revealed two sons were identified to be contacted in case of emergency. Review of the quarterly Minimum Data Set completed on 10/01/19 indicated no cognitive delay. Resident #79 was identified as requiring supervision with all activities of daily living. Review of the fall risk evaluation completed on 07/22/19 indicated Resident #79 was a low fall risk, had no falls during the past 90 days, no cognitive status change, adequate vision, independent with mobility and continent. Resident #79 balance was not steady, however able to stabilize self with assistive device and no change in blood pressure was noted. A fall risk evaluation dated 10/16/19 indicated high risk for fall, had one fall in the past 90 days, no change in cognitive status or behaviors noted, adequate vision, continent and ambulates with assistance of devices. Balance not steady, but able to stabilize with assistive devices. A nursing progress note on 07/22/19 at 4:45 A.M. indicated the nurse entered Resident #79 room room after hearing a knocking sound. Resident #79 was found sitting on her bottom in the door way coming out of her bathroom, covered with blood from laceration on left forehead. The nursing note indicated blood was also noted in the middle of the bathroom floor. Vital signs were obtained and a call was placed to 911 for transportation to the emergency room for evaluation. The nursing notes indicated an attempt was made to notify one son on 07/22/19 at 5:00 A.M., however phone was not set up for messages. Resident #79 returned to the facility on [DATE] at 8:45 A.M. with eight staples to her forehead. The nursing progress note did not indicate the physician was notified or any attempt to notify residents other responsible party. On 10/16/19 at 5:15 A.M. a nursing progress note indicated Resident #79 slid off the side of the bed to the floor and had a skin tear to the right arm. On 10/16/19 at 5:15 P.M. an nursing progress note indicated a follow up to post fall, dressing were currently ordered and were dry and intact. The nursing progress notes did not indicate the family or physician was notified. On 10/22/19 at 5:15 P.M. during an interview with the Director of Nurses (DON) she stated documentation of physician and family notification should be in the progress notes in the medical record and no documentation was noted in the electronic or hard chart indicating the physician or family were notified. Review of the facility policy Notification of Change in Resident's Condition, dated 08/2017, indicated to notify the physician of a change in the resident and document in the nursing notes and to notify the responsible party by calling the first name to be called on the resident's face sheet. If no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 5 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0580 response, call the second name and continue until someone is notified. Document notification in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 6 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure residents received written bed hold notifications within 24 hours of their discharges from the facility. This affected two (#21 and #56) of two residents reviewed for discharge notification. The facility census was 88. Findings include: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with the following diagnoses; difficulty in walking, hypertension, transient cerebral ischemic attack, chronic obstructive pulmonary disease, unspecified psychosis, anxiety disorder and major depressive disorder. Review of Resident #21's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #21 also required supervision with eating on the 07/20/19 MDS. Review of Resident #21's chart revealed resident was discharged to the psychiatric hospital for increased anxiety and agitation on 10/10/19. Resident #21 was readmitted to the facility on [DATE]. Review of Resident #21's bed hold notification for her 10/10/19 discharge to the hospital revealed Resident #21's resident representative was not mailed a written bed hold notification until 10/15/19. Interview with Business Office Manager #57 on 10/24/19 at 9:38 A.M. verified Resident #21's resident representative did not receive a written bed hold notifications within 24 hours of Resident #21's discharge to the hospital on [DATE]. 2. Record review revealed Resident #56 was admitted to the facility on [DATE] with the following diagnoses; respiratory failure, syncope and collapse, muscle weakness, altered mental status and other speech and language deficit. Resident #56 discharged from the facility on 10/21/19. Review of Resident #56's quarterly MDS assessment dated [DATE] revealed the resident to be cognitively intact and required extensive assistance with transfers, bed mobility, dressing and personal hygiene. Resident #56 also required limited assistance with toileting and supervision with eating on the 09/07/19 MDS. Review of Resident #56's chart revealed resident was discharged to the hospital on [DATE] with chest pains. Review of Resident #56's chart revealed no bed hold notice on file for Resident #56's discharge to the hospital on [DATE]. Interview with Business Office Manager #57 on 10/24/19 at 2:25 P.M. verified Resident #56 or Resident #56's resident representative did not receive a written bed hold notification upon Resident #56's discharge to the hospital on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 7 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0625 Review of the facility's Bed Hold Letter Policy dated October 2015 revealed the facility will track the resident's bed hold days and notify the appropriate parties using a bed hold letter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 8 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interviews, the facility failed to ensure a resident that remained in the facility had a pre-admission screening and resident review (PASARR) prior to admission to the facility. This affected one (#54) of one resident reviewed for PASARR. The facility census was 88. Residents Affected - Few Findings include: Record review revealed Resident #54 was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, bipolar disorder, other dysphagia, chronic obstructive pulmonary disease, hypothyroidism, unspecified abnormalities of gait and mobility, muscle weakness and unsteadiness on feet. Review of Resident #54's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with personal hygiene, toileting and dressing. Resident #54 also required supervision with bed mobility, transfers and eating on the 09/05/19 MDS. Review of Resident #54's chart revealed the resident did not have a pre-admission screening and resident review (PASARR) prior to being admitted and while residing at the facility. Interview on 10/22/19 at 9:56 A.M. with Social Services #73 verified Resident #54 did not have a PASARR on file at the facility despite her being admitted to and residing in the facility since 08/24/14. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 9 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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** 2. Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, anxiety, Alzheimer's disease, unspecified psychosis (07/31/19), and artificial right hip joint. Review of the quarterly MDS completed on 08/08/19 indicated Resident #35 had severe cognitive impairment, required extensive assistance of two staff for activities of daily living. The staff assessment of Resident #35 mood revealed depressed, trouble falling asleep, feeling tired, appetite concerns. Resident #35 had indicators for psychosis including delusions and no behaviors were identified. A review of the physician orders indicated Resident #35 was currently receiving Meloxicam 7.5 milligrams (mg) daily for inflammation, Levothyroxine Sodium 25 micrograms (mcg) daily for hypothyroidism, Tramadol 50 mg two times daily for pain and Tylenol 325 mg two tablets ever four hours as needed for pain. The physician orders indicated Lovenox (an anticoagulant) was discontinued on 01/14/19 and Risperidone (an antipsychotic medication) was discontinued on 08/28/19. A review of Resident #35 plan of care on 10/23/19 indicated Resident #35 was receiving anticoagulant and psychotropic medication. On 10/23/19 at 12:02 P.M. Licensed Practical Nurse (LPN) #30 reported knowing Resident #35 and was familiar with his medications. LPN #30 stated Resident #35 was currently not receiving any psychotropic or anticoagulant medications. During an interview with Registered Nurse (RN) #101 on 10/23/19 at 1:46 P.M. she reported she was responsible for Resident #35 plan of care and had not updated the plan of care when the anticoagulant medication or psychotropic medication was discontinued. Based on observation, medical record review, staff and resident interview and policy review, the facility failed to update and revise residents care plans for two residents (#20 and #35) and failed to involve one resident (#89) in their care planning participation. This affected three (#20, #35, and #89) out of 21 residents reviewed for care planning. The facility census was 88. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 05/20/16 with diagnoses including but not limited to dementia, history of falling, hypertension, and anxiety. Review of the quarterly minimum data set assessment (MDS) dated [DATE] revealed cognitive status was not assessed, she received extensive assistance for toileting and hygiene needs and was frequently incontinent of bladder. Review of social service note dated 10/18/19 revealed Resident #20 had severe cognitive impairment. Review of physician orders dated October 2019 revealed Resident #20 is to use the bedside commode. Review of care plan revealed Resident #20 had an activity of daily living performance deficit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 10 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 related to limited mobility and required assistance with toileting and intervention included bedside commode. Resident #20 has bladder incontinence related to dementia and impaired mobility. Observation was conducted on 10/21/19 at 12:17 P.M. and Resident #20 had urinated on her bedroom floor. Observation was conducted on 10/22/19 at 1:38 P.M. and on 10/23/19 at 9:02 A.M. and noted a very strong urine odor from Resident #20's room. Interview was conducted on 10/22/19 at 1:45 P.M. with State Tested Nursing Assistant (STNA) #34 and she stated that Resident #20 will not keep any attend on and will throw them in the corner. She stated Resident #20 uses a bedside commode but will still urinate all over the floor and they placed the bedside commode in front of the bathroom door because she was urinating all over the bathroom floor that other residents use. Interview was conducted on 10/23/19 at 9:35 A.M. with STNA #16 and she stated Resident #20 will take herself to the bathroom and will not leave pull ups on and they have to change her at least once a day. She stated she does have a bedside commode and will urinate on floor in front of it and all over her room. Interview was conducted on 10/23/19 at 11:15 A.M. with Social Service Staff #73 and she verified there was no care plan in place prior to 10/22/19 for Resident #20 urinating one the bedroom floor and that it had been an ongoing problem. 3. Record review of Resident #89's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, insomnia, hypocalcemia, dementia with behavioral disturbance, muscle weakness, dissociative conversion disorder, epilepsy anemia, other nail disorder and dysphagia. Review of Resident #89's quarterly MDS assessment dated [DATE] revealed resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #89 also required supervision with eating on the 09/30/19 MDS. Review of Resident #89's chart revealed resident was invited but did not attend a care conference on 10/09/19. Further review of Resident #89's chart revealed resident did not have and was not invited to any care conferences prior to the care conference held on 10/09/19. Interview with Resident #89 on 10/21/19 at 12:54 P.M. revealed he had not been invited to care conference and had not been given the opportunity to participate in the care planning process. Interview with Social Services #73 on 10/23/19 at 3:03 P.M. verified Resident #89 did not have a care conference and was not invited to participate in care planning prior to his care conference held on 10/09/19 despite Resident #89 residing at the facility since 08/11/16. Review of the facility's Care Conference policy dated August 2015 revealed the facility will hold regular interdisciplinary care conferences. The policy also revealed each resident shall be invited to care conference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 11 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 policy review, the facility failed to provide timely incontinence care to a resident. This affected one (#20) out of two residents reviewed for activities of daily living. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 05/20/16 with diagnoses including but not limited to dementia, history of falling, hypertension, and anxiety. Review of the quarterly minimum data set assessment dated [DATE] revealed cognitive status was not assessed, she received extensive assistance for toileting and hygiene needs and was frequently incontinent of bladder. Review of social service note dated 10/18/19 revealed Resident #20 had severe cognitive impairment. Review of physician orders dated October 2019 revealed Resident #20 is to use the bedside commode. Review of care plan revealed Resident #20 had an activity of daily living performance deficit related to limited mobility and required assistance with toileting and intervention included bedside commode. Resident #20 has bladder incontinence related to dementia and impaired mobility and included intervention to provide incontinence care and change clothing as needed after incontinent episodes. Observation was conducted on 10/23/19 at 12:58 P.M. and noted Resident #20 propelling self in her wheelchair down the hallway with incontinence of urine visible through her pants with urine odor. Observation was conducted on 10/23/19 at 2:05 P.M. and Resident #20 was sitting in dining room/lounge area with other residents watching television. Resident #20 remained with visible incontinence of urine through her pants. Observation was conducted on 10/23/19 at 2:49 P.M. with Resident #20 and she was propelling self down hallway in wheelchair and had the same pants on with dry incontinent stain of urine noted on front of pants. Observation was conducted on 10/23/19 at 3:10 P.M. of Resident #20 propelling self down hallway in wheelchair with large amount of incontinence of urine going down both legs of her pants and strong urine smell. Interview was conducted on 10/23/19 at 3:21 P.M. with Licensed Practical Nurse (LPN) #30 and she verified large amount of incontinence of urine visible for Resident #20 as well as previous dried urine stains on pants from earlier incontinent episode. Review of facilities Incontinent Resident Care Policy dated November 2015 revealed incontinent residents will be cared for by nursing personnel to ensure adequate skin care, control odor, and provide personnel hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 12 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, observation and staff and resident interview , the facility failed to conduct an accurate skin assessment of a resident's skin tear. This affected on (#79) of 18 residents reviewed. Facility census was 88. Residents Affected - Few Findings include: Review of Resident #79's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteoporosis with history of pathological fracture, anxiety, depression, emphysema, history of cerebral infarction, and endometrium cancer. Review of the quarterly Minimum Data Set completed on 10/01/19 indicated no cognitive delay. Resident #79 was identified as requiring supervision with all activities of daily living. A nursing progress noted dated 10/16/19 at 5:15 A.M. indicated Resident #79 slid off the side of the bed onto the floor which resulted in a skin tear to right arm. A post fall nursing progress note on 10/16/19 at 5:15 PM. indicated the resident's skin tone was normal, skin warm and dry. Dressing was dry and intact. A physician order dated 10/16/19 indicated to cleanse a skin tear on the right lateral arm with normal saline, apply steri strips and monitor for signs and symptoms of infections until resolved. Resident #79 plan of care dated 10/16/19 indicated impairment to skin integrity related to a skin tear to the right arm. Interventions included assess area for signs/symptoms of infection, treat per physician order, document, educate and laboratory tests per order. The bi-weekly skin assessment dated [DATE] revealed no current skin issues. The bi-weekly skin assessment dated [DATE] indicated a skin issue to the right elbow with treatment in place. Observation of Resident #79 on 10/21/19 at 11:29 A.M. revealed steri-strips noted to right arm. Resident #79 reported on 10/23/19 at 10:45 A.M. the injury (skin tear) to her arm occurred when she fell out of bed and 'laid open' the area on her arm. During an interview with the Director of Nurses (DON) on 10/23/19 at 10:56 A.M. confirmed the skin assessment on 10/17/19 was inaccurate due to documentation of laceration on 10/16/19 to right arm and skin assessment identified no skin concerns, however documentation of a fall on 10/16/19 identified a laceration to the right elbow with steri strips applied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 13 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure a resident received appropriate care and services to prevent a further decline in the resident's contractures. This affected one (#78) of two residents reviewed for range of motion. The facility census was 88. Findings include: Record review revealed Resident #78 was admitted to the facility on [DATE] with the following diagnoses; Huntington disease, restlessness and agitation, flaccid hemiplegia affecting right dominant side, dysphagia, muscle weakness, contracture of right knee, contracture of left knee, unspecified dementia with behavioral disturbance and hyperlipidemia. Review of Resident #78's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required total dependence with bed mobility, eating, transfers, dressing, toileting and personal hygiene. Review of Resident #78's occupational therapy Discharge summary dated [DATE] revealed resident was to have range of motion and palm protectors placed. Review of Resident #78's chart revealed no information regarding resident receiving range of motion from 10/01/19 to 10/24/19. Review of Resident #78's care plan dated 09/17/19 revealed resident will wear bilateral palmar orthotic at all times for positioning of bilateral hands. Review of Resident #78's orders revealed resident was ordered to wear bilateral palmar orthotics at all times for positioning of bilateral hands on 02/11/19. Observation of Resident #78 on 10/21/19 at 11:31 A.M. revealed resident to be sitting in his wheelchair in the activities room. Resident #78 was observed to have bilateral contractures to his hands with no devices in place. Observation of Resident #78 on 10/22/19 at 3:01 P.M. revealed resident to be sitting in his wheelchair in the activities room. Resident #78 was observed to have bilateral contractures to his hands with no devices in place. Observation of Resident #78 on 10/22/19 at 4:54 P.M. revealed resident to be sitting in his wheelchair in the activities room. Resident #78 was observed to have bilateral contractures to his hands with no devices in place. Observation of Resident #78 on 10/23/19 at 9:01 P.M. revealed resident to be asleep in bed. Resident #78 was observed to have bilateral contractures to his hands with no devices in place. Observation of Resident #78 on 10/23/19 at 11:59 A.M. revealed resident to be sitting in his wheelchair in the activities room. Resident #78 was observed to have bilateral contractures to his hands with no devices in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 14 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Interview with Licensed Practical Nurse (LPN) #30 on 10/23/19 at 11:59 A.M. verified Resident #78 was not wearing his bilateral palmar orthotics as ordered and listed on his care plan. Interview with the Director of Nursing (DON) on 10/24/19 at 12:08 P.M. verified Resident #78 did not receive any range of motion or restorative therapy from 10/01/19 to 10/24/19. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 15 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #25 revealed an admission date of 04/18/16 with pertinent diagnosis of: anxiety disorder, heart failure, essential hypertension, hyperlipidemia, hypothyroidism, abdominal hernia, arthropathy, diverticulitis of intestine, muscle weakness, psychosis, dementia with behavioral disturbance, visual hallucinations, malaise, dysphagia, asthma, age related osteoporosis, major depressive do, dry eye syndrome, blindness in one eye, hearing loss, difficulty in walking, and chronic obstructive pulmonary disease. Review of the 07/23/19 quarterly MDS assessment revealed Resident #25 is never or rarely understood and requires extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident is always incontinent of bowel and bladder and uses a walker to aid in ambulation. Review of the medical record on 10/23/19 revealed pharmacy recommendations were made for Resident #25 on the dates of 04/22/19, 05/20/19, 06/17/19 and 08/19/19. There was no record of the pharmacy recommendations in the medical record or that they were seen by the physician. Interview with the Director of Nursing (DON) on 10/24/19 at 12:10 P.M. verified there was no signed pharmacy recommendations for Resident #25 for the dates of 04/22/19, 05/20/19, 06/17/19 and 08/19/19. Based on medical record review and staff interview, the facility failed to ensure the physician had review the monthly pharmacist drug regimen review and any concerns were addressed in a timely manner. This affected two (#15 and #25) of five residents reviewed for unnecessary medications. Facility census was 88. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia, heart failure, malaise, major depression and malignant neoplasm of esophagus. Review of the quarterly Minimum Data Set (MDS) completed on 10/04/19 indicated Resident #15 had severe cognitive impairment. Resident #15 required one person limited assistance with mobility, one person extensive assistance with dressing, eating, toilet use and personal hygiene. No indications for psychosis were identified. Antipsychotics were used on a daily basis and no gradual dose reduction (GDR) was done since the past review. Review of the physician orders revealed Risperidone (a psychotropic medication) one milligram (mg) from 01/24/19 through 03/16/19, Risperidone 0.5 mg from 03/17/19 through 06/19/19 and Risperidone 0.25 mg from 06/19/19 through 09/21/19 when the medication was to be discontinued. Review of the monthly pharmacy review for 02/19/19, 06/18/19 and 09/17/19 indicated to see report for irregularities. Review of the medical record and electronic medical record did not contain the pharmacist report of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 16 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 irregularities. Level of Harm - Minimal harm or potential for actual harm On 10/24/19 at 1:32 P.M. during an interview with the Director of Nurses (DON) she reported the facility was unable to locate the pharmacy recommendations made to the physician. The DON stated the recommendations were received on green paper, which was then copied and given to medical records for physician review. The DON stated after the physician reviewed the recommendation and approved or disapproved, any orders were to be placed on the residents chart and the signed green recommendation form would be returned to medical records. The DON stated medical records was unable to locate these forms. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 17 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of medication information from Medscape, the facility failed to ensure residents drug regimen were free from unnecessary medications when Resident #25 was prescribed Ranexa (a drug used to treat angina, chest pain) without an accurate diagnosis. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 88. Residents Affected - Few Findings include: Record review of Resident #25 revealed an admission date of 04/18/16 with pertinent diagnosis of: anxiety disorder, heart failure, essential hypertension, hyperlipidemia, hypothyroidism, abdominal hernia, arthropathy, diverticulitis of intestine, muscle weakness, psychosis, dementia with behavioral disturbance, visual hallucinations, malaise, dysphagia, asthma, age related osteoporosis, major depressive do, dry eye syndrome, blindness in one eye, hearing loss, difficulty in walking, and chronic obstructive pulmonary disease. Review of the 07/23/19 quarterly Minimum Data Set (MDS) assessment revealed Resident #25 is never or rarely understood and requires extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The Resident is always incontinent of bowel and bladder and uses a walker to aid in ambulation. Review of a Physicians Order dated 06/22/19 revealed an order for Ranexa (a drug used to treat angina, chest pain) 500 milligrams give by mouth two times a day for gastro esophageal reflux disease. Interview with the Director of Nursing on 10/24/19 at 12:10 P.M. verified the order for Ranexa was being given without an accurate diagnosis for the medication. Review of medication information from Medscape revealed Ranexa is an antianginal and is used for chronic angina or chest pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 18 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure a resident was free from unnecessary medication when the staff failed to implement a gradual dose reduction (GDR) for an antipsychotic medication as ordered by the physician. This affected one (#15) of five residents reviewed for unnecessary medications. Facility census was 88. Findings include: Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia, heart failure, malaise, major depression and malignant neoplasm of esophagus. Review of the quarterly Minimum Data Set completed on 10/04/19 indicated Resident #15 had severe cognitive impairment. Resident #15 required one person limited assistance with mobility, one person extensive assistance with dressing, eating, toilet use and personal hygiene. No indications for psychosis were identified. Antipsychotics were used on a daily basis and no GDR had occurred since the past review. Review of the physician orders revealed Risperidone (a psychotropic medication) one milligram (mg) from 01/24/19 through 03/16/19, Risperidone 0.5 mg from 03/17/19 through 06/19/19 and Risperidone 0.25 mg from 06/19/19 through 09/21/19 when the medication was to be discontinued. Review of the Medication Administration Record (MAR) indicated Resident #15 continued to receive Risperidone 0.25 mg two times daily 09/22/19 through 10/06/19. A nursing progress note on 10/16/19 at 1:42 P.M. indicated Resident #15 had a physician order to discontinue Risperidone 0.25 mg two times daily on 09/22/19 however the medication was not discontinued until 10/07/19. On 10/24/19 at 1:32 P.M. during an interview with the Director of Nurses (DON) she stated Resident #15 physician had approved discontinuing the Risperidone, however the nurse did not transfer the order to the MAR when it was sent to pharmacy. Review of facility policy Physician Orders, dated 10/2015 indicated the charge nurse shall transcribe and review all physician orders in order to effect their implementation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 19 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #25 revealed an admission date of 04/18/16 with pertinent diagnosis of: anxiety disorder, heart failure, essential hypertension, hyperlipidemia, hypothyroidism, abdominal hernia, arthropathy, diverticulitis of intestine, muscle weakness, psychosis, dementia with behavioral disturbance, visual hallucinations, malaise, dysphagia, asthma, age related osteoporosis, major depressive do, dry eye syndrome, blindness in one eye, hearing loss, difficulty in walking, and chronic obstructive pulmonary disease. Residents Affected - Few Review of the 07/23/19 quarterly MDS assessment revealed Resident #25 is never or rarely understood and requires extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident is always incontinent of bowel and bladder and uses a walker to aid in ambulation. Review of a Physicians Order dated 10/02/17 revealed an order to draw a prealbumin lab (a test to see if you are getting enough protein in your diet) every three months with no stop date. Review of the medical record on 10/23/19 revealed a lab for prealbumin was drawn on 09/02/19. No other lab for prealbumin was able to be found within the last year. Interview with Registered Nurse (RN) #37 on 10/24/19 at 2:20 P.M. verified the only lab she can find for prealbumin in the medical record or the computer is from 09/02/19. Based on medical record review, staff and resident interviews, and policy review the facility failed to obtain labwork and urinalysis per physician orders. This affected two (#13 and #25) out of seven residents reviewed for labs. The facility census was 88. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 04/13/18 with diagnoses including but not limited to end stage renal dialysis, urinary tract infection, retention of urine, and panic disorder. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #13 had no cognitive deficits, had presence of indwelling Foley catheter, and received dialysis treatment. Review of physician telephone order dated 07/03/19 revealed order to obtain urinalysis due to blood in urine. Review of the medical record was silent that any urinalysis was obtained as ordered on 07/03/19. Review of care plan revealed Resident #13 had urinary retention, presence of catheter, history of urinary tract infections (UTI's), and is non compliant with catheter care and keeps her catheter at waist level. Interview was conducted on 10/21/19 at 10:48 A.M. with Resident #13 and she stated the facility did not check her urine a couple months ago. She stated she has history of frequent UTI's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 20 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0770 Level of Harm - Minimal harm or potential for actual harm Interview was conducted on 10/23/19 at 1:01 P.M. with the Director of Nursing and she verified they did not have urinalysis that was ordered on 07/03/19. Review of facilities Physician Orders Policy dated October 2015 revealed the charge nurse shall transcribe and review all physician orders in order to effect their implementation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 21 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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, observation and staff and resident interview, the facility failed to ensure dental services were offered to residents. This affected one (#3) of one residents reviewed for dental concerns. Facility census was 88. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including depression, asthma, seizures, hypertension, colostomy status, anxiety, history of wound to buttock and developmental disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated no cognitive delay and required one person extensive physical assistance for person hygiene including brushing teeth. The annual MDS dated [DATE] indicated no dental concerns. Review of State Tested Nursing Assistant (STNA) documentation for 09/2019 and 10/2019 indicated Resident #3 was extensive assistance of one person for oral hygiene which was provided two times daily. Review of the physician orders for Resident #3 indicated services per ancillary services as needed. No documentation was present in Resident #3's electronic record or the hard chart of dental services provided. During an interview with Resident #3 on 10/21/19 at 3:53 P.M. debris was noted at the gumline, between and on teeth. Resident #3 teeth appeared as though they needed cleaned. During an interview Social Service Designee (SSD) #73 reported on 10/22/19 at 2:24 P.M. she was the contact person for dental services at the facility. SSD #73 stated all services provided by dental, vision, auditory and podiatry were kept in her office and not placed in the medical record. She stated Resident #3 normally refused all dental consults. On 10/22/19 at 3:27 P.M. STNA #60 reported she normally worked on the hall with Resident #3. STNA #60 stated she could normally get Resident #3 to allow care to be given 200 Hall and was familiar with Resident. Stated normally could get him to allow care to be given. On 10/23/19 at 10:54 A.M. Resident #3 stated did not always get his teeth brushed and was not sure why. Resident #3 stated he would like to see the dentist. During an interview with SSD #73 she reported on 10/23/19 at 10:58 A.M. she was unable to determine the last time Resident #3 had been referred to see the dentist. SSD #73 stated she did not have any information regarding dental referrals for Resident #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 22 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review of Resident #25 revealed an admission date of 04/18/16 with pertinent diagnosis of: anxiety disorder, heart failure, essential hypertension, hyperlipidemia, hypothyroidism, abdominal hernia, arthropathy, diverticulitis of intestine, muscle weakness, psychosis, dementia with behavioral disturbance, visual hallucinations, malaise, dysphagia, asthma, age related osteoporosis, major depressive do, dry eye syndrome, blindness in one eye, hearing loss, difficulty in walking, and chronic obstructive pulmonary disease. Review of the 07/23/19 quarterly MDS assessment revealed Resident #25 is never or rarely understood and requires extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident is always incontinent of bowel and bladder and uses a walker to aid in ambulation. Review of the medical record on 10/23/19 revealed no physician monthly progress notes were in the medical record for the last year. Interview with the Director of Nursing (DON) on 10/23/19 at 10:22 A.M. revealed the physician sends progress notes to the DON by computer and then the physician would send a signed copy at a later date for medical records which was placed in the files. The DON confirmed no signed progress notes in the medical record was available for staff to review. Interview with the DON on 10/24/19 at 9:31 A.M. verified there was no physician monthly progress notes in the medical record in the last year for Resident #25. 5. Review of the medical record for Resident #13 revealed an admission date of 04/13/18 with diagnoses including but not limited to end stage renal dialysis, diabetes mellitus, urinary tract infection, heart failure, retention of urine, and panic disorder. Review of quarterly MDS assessment dated [DATE] revealed Resident #13 had no cognitive deficits, had presence of indwelling Foley catheter, and received dialysis treatment. Review of the electronic and paper medical record for Resident #13 was silent for any physician progress notes. During the survey, the Director of Nursing and Administrator was able to obtain physician progress notes dated 04/28/19, 06/29/18, 07/21/19, 08/23/19, and 09/22/19. There was none for May 2019 and prior to April 2019. Interview was conducted on 10/23/19 at 10:22 A.M. with the Director of Nursing and she stated the physicians would send her their progress notes once dictated via computer. She verified there was no physician progress notes for Resident #20 in medical record for nurses to review. Interview was conducted on 10/23/19 at 10:56 A.M. with the Administrator and she stated she did not know why the physician progress notes were not in residents chart. She stated they tried to call the physician but he was out of town. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 23 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0842 Level of Harm - Minimal harm or potential for actual harm Interview was conducted on 10/24/19 at 11:28 A.M. with the Director of Nursing and she stated the physician comes in and then later dictates the progress notes and she received them via email and then she would print them and take to medical records to place in physician's folder to sign and then they were supposed to be filed in the residents charts. The Director of Nursing verified they were not all being placed in charts and they had some work to do on this. Residents Affected - Some 6. Review of the medical record for Resident #77 revealed an admission date of 08/03/18 with diagnoses including but not limited to wernickes encephalopathy, seizures, and diabetes mellitus. Review of the annual MDS assessment dated [DATE] revealed she had some moderate cognitive deficits, received scheduled pain medication, total assistance with transfers, and had range of motion limitations to both lower extremities. Review of the electronic and paper medical record for Resident #77 was silent for any physician progress notes. During the survey, the Director of Nursing and Administrator was able to obtain physician progress notes dated from March 2019 through September 2019 for Resident #77. Interview was conducted on 10/23/19 at 10:22 A.M. with the Director of Nursing and she stated the physicians would send her their progress notes once dictated via computer. She verified there was no physician progress notes for Resident #77 in medical record for nurses to review. Interview was conducted on 10/23/19 at 10:56 A.M. with the Administrator and she stated she did not know why the physician progress notes were not in residents chart. She stated they tried to call the physician but he was out of town. Interview was conducted on 10/24/19 at 11:28 A.M. with the Director of Nursing and she stated the physician comes in and then later dictates the progress notes and she received them via email and then she would print them and take to medical records to place in physician's folder to sign and then they were supposed to be filed in the residents charts. The Director of Nursing verified they were not all being placed in charts and they had some work to do on this. Based on record review and interview, the facility failed to ensure physician visit notes were accessible in the resident's medical record. This affected seven (#21, #78, #54, #12, #13, #77 and #25) of 18 residents reviewed for complete and accessible medical records. The facility census was 88. Findings include: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with the following diagnoses; difficulty in walking, hypertension, transient cerebral ischemic attack, chronic obstructive pulmonary disease, unspecified psychosis, anxiety disorder and major depressive disorder. Review of Resident #21's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #21 also required supervision with eating on the 07/20/19 MDS. Review of Resident #21's chart on 10/23/19 revealed no physician visits noted in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 24 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0842 electronic or paper chart. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on 10/23/19 at 10:22 A.M. verified none of the physician visits were accessible in Resident #21's electronic or paper record. The DON reported all physician visits were kept in the medical records department and were not accessible to staff. Residents Affected - Some 2. Record review revealed Resident #78 was admitted to the facility on [DATE] with the following diagnoses; Huntington disease, restlessness and agitation, flaccid hemiplegia affecting right dominant side, dysphagia, muscle weakness, contracture of right knee, contracture of left knee, unspecified dementia with behavioral disturbance and hyperlipidemia. Review of Resident #78's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and required total dependence with bed mobility, eating, transfers, dressing, toileting and personal hygiene. Review of Resident #78's chart on 10/23/19 revealed no physician visits noted in the resident's electronic or paper chart. Interview with the Director of Nursing on 10/23/19 at 10:22 A.M. verified none of the physician visits were accessible in Resident #78's electronic or paper record. The DON reported all physician visits were kept in the medical records department and were not accessible to staff. 3. Record review revealed Resident #54 was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, bipolar disorder, other dysphagia, chronic obstructive pulmonary disease, hypothyroidism, unspecified abnormalities of gait and mobility, muscle weakness and unsteadiness on feet. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with personal hygiene, toileting and dressing. Resident #54 also required supervision with bed mobility, transfers and eating on the 09/05/19 MDS. Review of Resident #54's chart on 10/23/19 revealed no physician visits noted in the resident's electronic or paper chart. Interview with the Director of Nursing on 10/23/19 at 10:22 A.M. verified none of the physician visits were accessible in Resident #54's electronic or paper record. The DON reported all physician visits were kept in the medical records department and were not accessible to staff. 4. Record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; muscle weakness, other lack of coordination, difficulty in walking, anxiety disorder, schizophrenia, psychosis, restlessness and agitation, heart failure and edema. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and required total dependence with bed mobility, transfers and toileting. Resident #12 also required extensive assistance with personal hygiene and dressing and limited assistance with eating on the 10/03/19 MDS. Review of Resident #12's chart on 10/23/19 revealed no physician visits noted in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 25 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0842 electronic or paper chart. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on 10/23/19 at 10:22 A.M. verified none of the physician visits were accessible in Resident #12's electronic or paper record. The DON reported all physician visits were kept in the medical records department and were not accessible to staff. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 26 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 medical record review, observation, staff interview and policy review, the facility failed to ensure proper infection control techniques were maintained while providing care in an isolation room and in the facility laundry room. This affected one (#14) randomly observed resident receiving care by staff who was in isolation precautions and also had the potential to affect all 88 residents whose laundry was completed at the facility. The facility census was 88. Residents Affected - Many Findings include: 1. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, hypertension, diabetes mellitus Type II, cerebral infarction, mild cognitive impairment and pseudobulbar affect. Review of the physician orders for Resident #14 included an order on 08/24/19 for contact isolation due to infection (Pseudomonas and Methicillin Resistant Staphylococcus Aureus (MRSA)) in a heel wound which continued to be current on the 10/2019 physician monthly orders. On 10/21/19 at 2:43 P.M. Social Service Designee (SSD) #73 was observed in Resident #14 room handling bed linen and personal property. SSD #73 did not have have any type of Personal Protective Equipment (PPE) on. The Assistant Director of Nurses (ADON) confirmed Resident #14 was on contact isolation for a wound to her heel and anyone touching any articles in the room should have a gown and gloves on. The ADON confirmed SSD #73 did not have any PPE on and instructed her to apply PPE. On 10/21/19 at 2:46 P.M. Maintenance Staff #72 was observed in Resident #14 room without any PPE. Maintenance Staff #72 was observed to touch the remote control used by Resident #14 and her television. On 10/21/19 at 2:50 P.M. Maintenance Staff #72 reported he drove the bus for the facility and had been in Resident #14 room working on the television and remote. Maintenance Staff #72 stated did not have to use any PPE due to only working on television and not touching the resident. Review of the facility policy Transmission Based Precautions, dated 07/2019 revealed contact precautions were to be utilized with direct or indirect contact with the resident or the resident's environment. 2. During tour of the laundry area on 10/24/19 at 2:32 P.M. with Maintenance Supervisor #75 and Medical Records Staff #59 one laundry barrel was observed overflowing with the lid unable to be secured. The linen in the laundry barrel was not in bags and was soiled. Maintenance Supervisor #75 reported all laundry was to be maintained in bags and laundry barrel lids were to be secured. Medical Records Staff #58 stated all laundry was to be maintained in bags until placed in the washing machine. The facility confirmed this had the potential to affect all residents residing in the facility. Review of the facility policy Soiled Linen Handling, dated 07/2019 revealed linen would be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 27 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, review of a dryer cleaning schedule and policy review, the facility failed to ensure the dryer was properly cleaned. This had the potential to affect all 88 residents residing at the facility. Additionally, the facility failed to maintain a sanitary and odor free environment. This had the potential to affect all 14 residents (#8, #13, #18, #20, #31, #33, #41, #43, #45, #77, #80, #81, #85, and #342) residing on the 400 unit. The facility census was 88. Findings Include: 1. During tour of the laundry area on 10/24/19 at 2:32 P.M. with Maintenance Supervisor #75 and Medical Records Staff #58 a build up of lint was noted in two of the three dryers in the laundry room. The dryers were empty. Review of the dryer cleaning schedule indicated the dryers had been free of lint at 1:00 P.M. The scheduled also indicated no laundry personal worked in the facility from 1:00 P.M. to 3:00 P.M. Maintenance Supervisor #75 and Medical Records Staff #58 confirmed the dryers were empty of any articles, the cleaning sheet indicated there was no lint at 1:00 P.M., there was no staff currently working in the laundry department. They confirmed the lint build up in the two dryers. Medical Records Staff #58 stated the dryers were to be cleaned of all lint after usage and apparently this had not been completed as indicated. The facility confirmed this had the potential to affect all resident as all 88 residents residing in the facility have their laundry completed by the facility. 2. Multiple observations was conducted from 10/21/19 through 10/23/19 of strong urine smell down 400 hallway. Observation was conducted on 10/21/19 at 12:17 P.M. of Resident #20 and had urinated all over bedroom floor. Observation was conducted on 10/22/19 at 1:38 P.M. of very strong urine odor coming from Resident #20's room and into the hallway. There was urine on the floor in Resident #20's room. Observation was conducted on 10/23/19 at 9:02 A.M. and revealed a strong urine odor from Resident #20's room and into the hallway. Interview was conducted on 10/23/19 at 1:45 P.M. with State Tested Nursing Assistant (STNA) #34 and she stated that Resident #20 will not keep any attend on and will throw them in the corner. She stated Resident #20 uses a bedside commode but will still urinate all over the floor and they placed the bedside commode in front of the bathroom door because she was urinating all over the bathroom floor that other residents use. She stated it was all day long that Resident #20 will urinate everywhere. Interview was conducted on 10/23/19 at 9:35 A.M. with STNA #16 and she stated Resident #20 will take herself to the bathroom and will not leave pull ups on and they have to change her at least once a day. She stated she does have a bedside commode and will urinate on floor in front of it and all over her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 28 of 29 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 Interview was conducted on 10/23/19 at 9:39 A.M. with Housekeeper #17 and Housekeeper #64 and they stated they clean resident rooms once a day including sweeping and mopping. They stated they were aware of the strong urine odor in Resident #20's room and hallway and they try to clean it several times a day. The facility confirmed there are 14 residents (#8, #13, #18, #20, #31, #33, #41, #43, #45, #77, #80, #81, #85, and #342) residing on the 400 unit that could potentially be affected by the urine odor. Residents Affected - Many Review of facilities Environmental Cleaning and Disinfection Policy dated 07/19/19 revealed proper cleaning and disinfecting environmental surfaces is necessary to break the chain of infection. Surfaces that are visibly soiled should be cleaned and disinfected immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 29 of 29