Health inspection·August 25, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to timely implement a behavioral care plan. This affected one resident (#7) out of the three residents reviewed for mood and behavior. The facility census was 54. Findings include: Record review for Resident #7 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia without behavioral disturbances, anxiety disorder, sexual dysfunction, hypertension, and epileptic seizures. Review of the discharge Minimum Data Set (MDS) assessment, dated 06/28/22, revealed this resident had exhibited physical and verbal behaviors directed at others one to three days during the lookback period. Review of the progress note, dated 06/28/22, revealed this resident had been aggressive with another resident and was seen hitting the other resident with her cane. The resident was placed on 15 minute checks and was to be sent to another facility for behavioral management and medication review. Review of the facility census timeline for this resident revealed the resident was transferred out of the facility on 06/28/22 and returned to the facility on [DATE]. Review of the active care plans for this resident revealed a care plan addressing behaviors and providing interventions for behavior management was not implemented until 08/23/22. Observation on 08/22/22 from 10:55 A.M. through 11:10 A.M. revealed Resident #7 was extremely agitated and was being argumentative with staff. The resident was observed to stand in the doorway of Resident #6's room and tell the resident to shut up as he was talking and then walk back to her room. Interview with Registered Nurse (RN) #104 on 08/24/22 at 2:30 P.M. verified Resident #7 had behavioral problems and a care plan had not been implemented addressing the behavioral problems until 08/23/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 2 of 8 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 08/25/2022 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** Based on observation, interview, and record review, the facility failed to timely revise fall care plan interventions. This affected one resident (#35) out of the three residents reviewed for falls. The facility census was 54. Findings include: Record review for Resident #35 revealed this resident was admitted to the facility on [DATE] and had diagnoses including muscle weakness, unsteadiness on feet, chronic gout, depression, anxiety, and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/22, revealed this resident had moderately impaired cognition and was assessed to require supervision for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 11/02/18, revealed this resident was at risk for falls. Interventions included non-skid strips in front of chair, non-skid strips to floor beside bed, and reminder sign to ask for assistance with transfers and ambulation. Observation on 08/24/22 at 4:05 P.M. revealed Resident #35 was sitting in her recliner in her room. There were no non-skid strips present by the bed, in front of the chair, or anywhere else in the room. There was not a sign present in the room to remind the resident to ask for assistance with transfers and ambulation. Verified with Registered Nurse (RN) #210 at the time of the observation. Interview with the Director of Nursing (DON) on 08/24/22 at 4:15 P.M. revealed Resident #35 had recently had a room change at which time the Interdisciplinary Team had met and reviewed the residents fall interventions. The DON stated interventions including non-skid strips to the side of the bed and in front of the chair and the reminder sign to call for assistance had been agreed upon to be discontinued. The DON verified the interventions on the residents fall care plan had not been updated as agreed upon by the Interdisciplinary Team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 3 of 8 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 08/25/2022 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 observation, interview, and record review, the facility failed to ensure ordered medications was available and administered as ordered by the physician. This affected one resident (#36) out of the four residents observed for medication administration. The facility census was 54. Residents Affected - Few Findings include: Record review for Resident #36 revealed this resident was admitted to the facility on [DATE] and had diagnoses including heart failure, hypertension, atrial fibrillation, and Gastro-Esophageal Reflux Disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/22, revealed this resident had mildly impaired cognition and was assessed to require extensive assistance from two staff members for bed mobility, limited assistance from one staff member for transfers, and extensive assistance from one staff member for toileting. Review of the physicians order, dated 10/20/21, revealed an order to administer one capsule of Aspirin 162.5 milligram 24 hour Extended Release medication every day. Review of the active, discontinued, completed, and struck out physicians orders for this resident revealed there was not an order for the administration of the medication Protonix. Observation on 08/24/22 at 9:45 A.M. during medication administration revealed the medication Aspirin 162.5 milligram 24 hour Extended Release capsule was not available on the medication cart or in the facility emergency medication supply for administration to Resident #36. There were two cards of the medication Protonix 40 milligram Delayed Release Capsules on the cart which had multiple doses missing. Interview with Registered Nurse (RN) #210 on 08/24/22 at 9:45 A.M. verified the medication Aspirin 162.5 milligram 24 hour Extended Release capsule was not available in the facility for administration to the resident. RN #210 also verified there were two prescription cards of 40 milligram Protonix labeled with Resident #35's name present on the medication cart with multiple doses missing although there was not an order for the administration of the medication in the residents medical record. Interview with RN #104 on 08/24/22 at 2:30 P.M. verified the facility did not have the medication Aspirin 162.5 milligram 24 hour Extended Release capsules available for administration and did not have evidence of the facility ever having the medication available for administration to Resident #36. RN #104 stated an order for the administration of Protonix 40 milligram Extended Release tablets to Resident #36 had been sent to the facility pharmacy by an outside physician the resident had seen but the order had never been transcribed to the residents Medication Administration Record for administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 4 of 8 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 08/25/2022 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure accurate daily staffing postings were displayed. This affected all 54 residents residing in the facility. Residents Affected - Many Findings include: Observation on 08/22/22 at 10:30 A.M. revealed the daily staffing postings were displayed in a box located by the nursing station. The postings contained the date and resident census number, but did not contain any information regarding the nursing hours present in the facility. The postings were dated 08/11/22, 08/12/22, 08/13/22, 08/17/22, 08/18/22, and 08/22/22. Interview with Licensed Practical Nurse (LPN) #184 on 08/22/22 at 10:35 A.M. revealed the night shift nursing staff were to fill out the daily staffing postings and place them in box hanging on the wall by the nurses station. LPN #184 verified the postings hanging in the box on the wall by the nurses station contained the dates and resident census number, but did not contain the nurse staffing hours they were supposed to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 5 of 8 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 08/25/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy review, the facility failed to store foods, discard expired foods and maintain food equipment in sanitary condition. This had the potential to affect 54 residents who received food from the kitchen. The facility census was 54. Findings include: Observation on 08/22/22 at 9:37 A.M. revealed following sanitation violations in the main kitchen: 1. Two open orange juice containers in reach-in refrigerator with no open date. 2. One thickened water container in reach-in refrigerator with no open date. 3. Two cranberry juice containers in reach-in refrigerator with no open date. 4. One unlabeled and undated container of a white substance on storage shelf. 5. One bag of opened and unsealed shredded cheese in walk in refrigerator. 6. A tray of 12 individual bowls of cereal unlabeled and undated in the dry storage area. 7. One box of opened cream of wheat cereal with expired date of 03/01/22. In the dining area, the ice machine had ice scoops stored in containers that did not permit drainage. The containers were on top of the ice machine and the ice scoops were stored horizontally in the ice scoop containers. In the dining room, the observation of the resident refrigerator revealed the following sanitation violations: 1. Two pizza boxes containing pizza dated 07/25/22 and no identified resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 6 of 8 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 08/25/2022 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 0812 2. Level of Harm - Minimal harm or potential for actual harm Two containers of tomatoes dated 05/20/22. 3. Residents Affected - Many One opened loaf of bread undated. 4. Two containers of whole milk dated 07/12/22. In the dishwashing area, the floor had an area of 36 inches by 6 inches of missing and cracked tiles with noted food debris. In the kitchen cooking area, the hood vents above the stove and grill area, had visible grey dust directly over the cooking surface. Throughout the kitchen area and dish washing area, the ceiling was soiled with food debris and visible dust. Interview on 08/22/22 at 9:37 A.M. the Diet Manger, (DM), #181 verified the foods in the reach in refrigerator and in the resident refrigerator should have open dates, had labels and the expired foods should have been discarded. DM #181 verified opened perishable foods are to be discarded after seven days. The DM #181 verified the dishwasher floor tile needed repaired. DM #181 verified the hood vents had dust over the cooking area and the ice machine scoops should be stored vertically. Interview on 08/25/22 at 9:00 A.M. with Maintenance Director, (MD) # 186 and DM #181 verified the hood vents had dust above the cooking surface and needed cleaned. The MD #186 stated although the hood cleaning contract company cleaned and inspected the hood in April 2022, and scheduled to return September 2022, the vents should be cleaned between visits of the contract company. The MD #186 verified the cracked and missing tiles in dishwashing area needed replaced and the ceiling needed cleaned. Review of facility policy, Storage of Refrigerated Foods Policy dated 02/19/19, and Hood and Filter Cleaning Instructions, undated, revealed refrigerator items must have a label, and a date the food should be consumed or discarded. Hood filters will be cleaned as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 7 of 8 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 08/25/2022 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation ,interview, and policy review, the facility failed to maintain food equipment in good repair. This had the potential to affect 54 residents who received food from the kitchen. The facility census was 54. Residents Affected - Many Findings include: Observation on 08/22/22 at 9:37 A.M. revealed the walk-in freezer had six inches by 24 inch area of ice buildup under the condenser at the back of the freezer. There was noted ice particles on top of and below food boxes stored below the condenser. Interview on 08/22/22 at 9:37 A.M. the Diet Manger, (DM) #181 verified the walk-in freezer had ice built up under the condenser and had not been working properly for several months. The DM #181 verified there was ice above and below boxes of frozen foods which did not permit proper air circulation. Interview on 08/25/22 at 9:00 A.M. with Maintenance Director, (MD) # 186 verified the walk-in freezer had ice built up under the condenser, had been occurring for a month and had not been removed or repaired. He verified a freezer condenser would not normally have an ice buildup. He verified the ice buildup would reduce air circulation in the freezer. Review of facility policy, Storage of Refrigerated Foods Policy dated 02/19/19 revealed all foods should be stored to allow air circulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 8 of 8