Inspection·October 14, 2021

F 0553 cognitively intact. Level of Harm - Minimal harm or potential for actual harm Review of Resident #17's medical record revealed the record was silent for documentation that care plan conferences had occurred. Additional review of Resident #17's medical record revealed a late progress note was entered on 10/13/21 at 3:52 P.M. for the date of 09/23/21 at 1:00 P.M. and it revealed a care conference had occurred. Residents Affected - Few Interview on 10/12/21 at 12:54 P.M. with Resident #17 revealed no knowledge of care plan conferences being held. Interview on 10/13/21 at 4:31 P.M. with the Administrator verified the facility had no documentation that care conferences were held for Resident #17. Based on medical record review, resident and staff interview, and review of the facility's policy, the facility failed to ensure residents and representatives were provided the opportunity to participate in care planning meetings. This affected three (#17, #31, and #48) of three residents reviewed for care conferences. The facility census was 61. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 02/07/17. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia without behavioral disturbance, and nonexudative age related macular degeneration. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/23/21, revealed Resident #31 was severely cognitively impaired, was independent with activities of daily living (ADL), and had wandering behavior. Review of the care plan revision dates revealed Resident #31's care plan was reviewed on 10/07/20, 01/18/21, 02/26/21, 03/10/21, 06/03/21, and 09/13/21. Review of a care plan progress note, dated 10/01/19, revealed Resident #31's guardian was present for the interdisciplinary care conference meeting. Additional review of Resident #31's medical record from 10/01/19 through 10/12/21, revealed it was silent for Resident #31 and/or the resident's guardian participation in care conference meetings. Interview on 10/14/21 at 9:01 A.M. with the Administrator verified the last interdisciplinary care conference meeting held that included Resident #31 and his guardian was on 10/01/19. The Administrator stated she met with the resident and his guardian in the resident's room a couple of months ago but Resident #31 and his guardian did not participate in the interdisciplinary care conference meetings. The Administrator stated she was aware the facility had challenges with care conference meetings and she was working on the challenges. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on record review, observation, staff interview, review of the facility's policy, review of the Centers for Medicare and Medicaid Services (CMS) QSO-20-39-NH, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to have the dining room open and available for residents to participate in communal dining. This had the potential to affect all residents, except for Residents #17, #19, #35, #37, #38, #39, #40, #44, #46, #49, and #153 identified by the facility as being unvaccinated, Resident #22 identified by the facility as having nothing by mouth, and Residents #6, #46, #202, #253, and #255 identified by the facility as new admissions. The facility census was 61. Findings include: Interview on 10/12/21 at 8:55 A.M. with [NAME] #337 revealed the dining room was closed and all meals were served in resident rooms. [NAME] #337 stated the dining room had been closed for a few weeks because the facility had positive COVID-19 residents and staff in the facility. Observation on 10/12/21 at 11:30 A.M. revealed the dining room was not open for resident use during lunch service. Continued observations from 11:45 A.M. to 12:30 P.M. revealed residents were served the lunch meal in their rooms. Observations from 10/13/21 at 8:00 A.M. through 10/14/21 at 12:30 P.M. revealed all resident meals were served in their rooms. Residents were not observed to participate in dining service in the dining room. Interview on 10/13/21 at 1:44 P.M. with State Tested Nurse Aide (STNA) #330 verified the dining room had been closed for a few weeks and residents had to eat in their rooms. STNA #330 stated the dining room was closed due to COVID-19. STNA #330 stated it was difficult for residents because they enjoyed going to the dining room and many had better meal intakes when they ate in the dining room. Interview on 10/14/21 at 9:51 A.M. with the Administrator verified the dining room was closed and not available to residents for dining service. The Administrator verified the dining room had been closed to residents since 09/20/21 following a staff member testing positive for COVID-19. The Administrator stated the facility was still in outbreak testing, which was going to be concluded this week and the staff who had previously tested positive for COVID-19 had worked in all areas of the facility. The Administrator stated she was protecting the residents from COVID-19 and following company policy. Review of the facility's records revealed Residents #17, #19, #35, #37, #38, #39, #40, #44, #46, #49, and #153 were identified by the facility as being unvaccinated, Resident #22 identified by the facility as having nothing by mouth, and Residents #6, #46, #202, #253, and #255 identified by the facility as new admissions Review of the facility's policy titled Communal Dining and Activities, dated 04/30/21, revealed the purpose was to provide a safe dining and activity experience while increasing socialization and quality of life. Additional review revealed dining may be curtailed if an outbreak occurred. Review of the CMS QSO-20-39-NH, revised 04/27/21 and located at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf, revealed while adhering to the core principles of COVID-19 infection prevention, communal dining may occur. The CDC has provided additional guidance on dining based on resident vaccination status. For example, residents who are fully vaccinated may dine and participate in activities without face coverings or social distancing if all participating residents are fully vaccinated; if unvaccinated residents are present during communal dining, then all residents should use face coverings when not eating and unvaccinated residents should physically distance from others. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, revised 09/10/21 and located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#:~:text=Interim%20Infection%20Prevention%20and% revealed fully vaccinated residents and residents with SARS-CoV-2 (COVID-19) infection in the last 90 days who had close contact with someone with SARS-CoV-2 infection do not need to be quarantined or restricted to their room unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident, family and staff interview, review of the facility's policy, review of the Centers for Medicare and Medicaid Services (CMS) QSO-20-39-NH, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to have communal group activities available for residents. This affected two (Residents #10 and #27) of two residents reviewed for activities. The facility census was 61. Residents Affected - Few Findings include: 1. Review of Resident #27's medical record reviewed an re-admission date of 05/21/21. Diagnoses included dementia without behavioral disturbance, difficulty in walking not elsewhere classified, vascular dementia with behavioral disturbance, macular degeneration, Type II Diabetes Mellitus without complications, and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment, dated 05/19/21, revealed it was somewhat important for Resident #27 to do things with groups of people and somewhat important to participate in favorite activities. The quarterly MDS assessment, dated 08/16/21, revealed Resident #27 was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs). Review of the plan of care, dated 05/19/21, revealed Resident #27 enjoyed activities such as animals/pets, arts and crafts, games (BINGO), music, parties and socials. Interventions included to encourage participation in group activities of interest. Observations from 10/12/21 at 9:51 A.M. through 10/14/21 at 9:04 A.M. of Resident #27 revealed the resident was sitting in her recliner, not engaged in activities. The television was on and tuned in to crime shows during each of the observations. Resident #27 was observed to be staring at her hands, staring at the wall, and sleeping in her recliner. Interview on 10/12/21 at 1:37 P.M. with a family member revealed there were not many activities available for Resident #27. The family member stated when she visited, the television usually had murder mystery shows on, which she stated Resident #27 would not have had an interest in. Interview on 10/13/21 at 1:44 P.M. with Stated Tested Nurse Aide (STNA) #330 revealed Resident #27 required extensive assistance with care. STNA #330 stated when group activities were available, Resident #27 would go so that she could get out of her room and be around other people. STNA #330 stated Resident #27 loved music and enjoyed going to music related group activities. STNA #27 stated activities would sometimes take a tablet into Resident #27's room to play music for her but it was not frequently done. STNA #330 stated Resident #27's roommate liked to watch crime television shows, which was why they were always on the television. 2. Review of Resident #10's medical record revealed an admission date of 04/16/21. Diagnoses included Parkinson's disease, dementia without behavioral disturbance, schizophrenia, Type II Diabetes Mellitus with hyperglycemia, bipolar disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the annual MDS assessment, dated 04/09/21 revealed Resident #10 was cognitively intact and it was somewhat important for her to do things with groups of people and to do her favorite (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 activities. Resident #10 was independent with ADLs. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care, revised on 04/13/18, revealed Resident #10 enjoyed activities such as bingo, parties, ladies group, and music therapy. Interventions included to encourage participation in group activities of interest. Residents Affected - Few Observation on 10/12/21 at 9:47 A.M. of Resident #10 revealed the resident was sitting alone in her room with the television on. Interview with Resident #10 at the time of the observation revealed prior to COVID-19, the facility had a number of group activities available. Resident #10 stated all she did now was sit in her room and be bored. Subsequent observations on 10/12/21 at 12:15 P.M. through 10/14/21 at 9:45 A.M. revealed Resident #10 was sitting in her room with the television on. Resident #10 was not observed to be participating in any activities during the three days. Interview on 10/13/21 at 1:52 P.M. with STNA #330 revealed Resident #10 enjoyed going to group activities. STNA #330 stated activities was trying but everything was shut down again because of a positive COVID-19 case. STNA #330 stated it was better for the residents when things group activities were available. Interview on 10/13/21 at 10:01 A.M. with Activities Assistant (AA) #359 revealed all activities were being done in resident rooms because of COVID-19. AA #359 stated she went room to room and asked residents if they wanted to participate in activities, such as coloring sheets and painting pumpkins. AA #359 verified there were no communal group activities occurring in the facility. AA #359 stated when group actives were available, staff would sit with residents who required more assistance so that they would be able to participate. AA #359 stated activities staff would try to sit in the room with residents to assist them with individual activities, such as coloring. If activities did have a hall activity, such as hallway bingo, staff were unable to assist residents who needed it since they were all in their rooms. Interview on 10/14/21 at 9:51 A.M. with the Administrator verified the facility was not offering communal group activities. The Administrator verified communal group activities had not been done since 09/20/21, following a staff member testing positive for COVID-19, but the activities department did have group activities available, such as hallway bingo. The Administrator stated the facility was still in outbreak testing, which was going to be concluded this week and the staff who had previously tested positive for COVID-19 had worked in all areas of the facility. The Administrator stated she was protecting the residents from COVID-19 and following company policy. Review of the facility's policy titled The Role of Activity and Recreation Services, dated July 2019, revealed the multi-faceted activity and recreation program creates a therapeutic environment that promotes cognitive, physical, social and sensory stimulation. Additionally, the center maintains and, or improves, a patient's physical, mental, and psychosocial well-being and independence and the center creates opportunities for each patient to have a meaningful life by supporting patients domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). Review of the facility's policy titled Communal Dining and Activities, dated 04/30/21, revealed the purpose was to provide a safe dining and activity experience while increasing socialization and quality of life. Additional review revealed dining may be curtailed if an outbreak occurs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the CMS QSO-20-39-NH, revised 04/27/21 and located at https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf, revealed while adhering to the core principles of COVID-19 infection prevention, communal activities may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The CDC has provided additional guidance on activities based on resident vaccination status. For example, residents who are fully vaccinated may participate in activities without face coverings or social distancing if all participating residents are fully vaccinated; if unvaccinated residents are present during communal activities, then all residents should use face coverings and unvaccinated residents should physically distance from others. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, revised 09/10/21 and located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#:~:text=Interim%20Infection%20Prevention%20and% revealed fully vaccinated residents and residents with SARS-CoV-2 infection in the last 90 days who had close contact with someone with SARS-CoV-2 infection do not need to be quarantined or restricted to their room unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, and staff interview, the facility to ensure an air mattress was functioning for a resident who was a high risk for pressure ulcers. This affected one (#18) of one resident reviewed for pressure ulcers. The facility identified 45 residents receiving preventative skin care. The facility census was 61. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 10/07/19. Diagnoses included muscle wasting and atrophy, Type II Diabetes Mellitus (DM), hypertension, and muscular dystrophy. Review of the annual Minimum Date Set (MDS) assessment, dated 07/23/21, revealed the resident required extensive assistance of two staff for bed mobility. The resident was at risk for pressure ulcers, had no unhealed pressure, and had a pressure reducing device for the bed. Review of the most recent care plan revealed the resident was at risk for alteration in skin integrity related to impaired mobility, reconditioning, and DM. Interventions include for a pressure redistributing device on bed and encourage to reposition as needed. Review of the the Braden scale for predicting pressure ulcers, dated 10/03/21, revealed the resident was a high risk for developing a pressure ulcer. Observations on 10/12/21 at 12:23 P.M. and on 10/14/21 at 9:09 A.M., revealed Resident #18 was lying in bed with the air mattress in place but the air mattress was turned off and was not inflated. Interview on 10/14/21 at 9:10 A.M. with the Director of Nursing (DON) reported Resident #18 had the air mattress in place due to a high risk for pressure ulcer. The DON stated the resident does not have a history of a pressure ulcer. The DON verified the air mattress device was unplugged from the wall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of the facility's policy, the facility failed to label oxygen tubing and place oxygen usage signage at a resident's room. This affected one (#253) of one resident reviewed for oxygen use. The facility identified 10 residents receiving oxygen at the facility. The facility census was 61. Residents Affected - Few Findings include: Review of Resident #253's medical record revealed an admission date of 10/11/21. Diagnoses included bacterial pneumonia, sepsis, metabolic encephalopathy, and muscle wasting and atrophy. Review of the plan of care, initiated 10/11/21, revealed Resident #253 had altered respiratory status/difficulty breathing related to history of pneumonia, chronic obstructive pulmonary disease (COPD), asthma, and chronic respiratory failure. Interventions included to administer oxygen as ordered. Review of the physician order, dated 10/11/21, revealed Resident #253 was ordered oxygen at two liters per minute via nasal cannula as needed to keep saturations above 92%. Observation on 10/12/21 at 12:24 P.M. of Resident #253 revealed the resident was on oxygen. The oxygen concentrator was set at two liters. There was no date observed on the oxygen tubing and no oxygen in use signage was posted at the resident's door. Subsequent observation on 10/13/21 at 11:18 A.M. of Resident #253 revealed the resident continued on oxygen with no oxygen in use sign posted at the door and oxygen tubing not dated. Interview on 10/13/21 at 11:22 A.M. with Stated Tested Nurse Aide (STNA) #330 verified an oxygen in use sign should be placed at a resident's room door who received oxygen. The STNA verified there was no signage posted at Resident #253's door. STNA #330 stated Resident #253 was a newer admission and she would take care of getting a sign for his room. In addition, STNA #330 verified Resident #253's oxygen tubing was not dated. Interview on 10/13/21 at 12:01 P.M. with Unit Manager (UM) #358 revealed oxygen tubing was changed weekly and was typically done by central supply staff. UM #358 stated a sign should be placed at a resident's room door to alert others of oxygen in use and tubing should be labeled with the date the tubing was changed. UM #358 stated there were generally no physician orders for the changing of tubing. Interview on 10/13/21 at 3:11 P.M. with Licensed Practical Nurse (LPN) #347 revealed she was helping in central supply as the staff in that position was no longer with the facility. LPN #347 stated central supply staff were responsible for changing oxygen tubing each week. LPN #347 stated there was no designated schedule and the central supply staff developed their own schedule for changing tubing. LPN #347 verified oxygen tubing should be labeled with the date it was changed and oxygen in use signage should be posted at the resident's room. Review of the facility's policy titled Oxygen Administration, updated July 2017, revealed the purpose was to describe method for delivering oxygen in order to improve tissue oxygenation, reduce risk for hypoxia, decrease work of breathing and reduce shortness of breath with activity. The procedure included place no smoking oxygen in use sign on doorway and change all tubing and masks as per state protocol and label with date and initials. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, resident and staff interview, and review of the facility's policy, the facility failed to ensure resident medications were not left unattended in a resident room. This affected one (#17) of one resident reviewed for self-administration of medication, with the potential to affect six additional residents (#2, #7, #23, #31, #39, and #207) who were identified by the facility as being cognitively impaired, and independently mobile. The facility census was 61. Findings include: Review of Resident #17's medical record revealed an admission date of 04/30/21. Diagnoses included cerebral infarction, chronic pain syndrome, muscle wasting and atrophy, epilepsy, adult failure to thrive, and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) assessment, dated 08/02/21, revealed Resident #17 was cognitively intact. Additional review of Resident #17's medical record revealed there was no self-medication assessment, a physician order for self-administration of medications, and there was no plan of care interventions for self-medication administration. Observation on 10/12/21 at 9:53 A.M. of Resident #17's room revealed a medication cup on the resident's tray table with pills in the cup. Interview with Resident #17 at the time of the observation revealed the pills were prescription medications that were left on his tray table and he had not taken them yet. Interview on 10/12/21 at 9:58 A.M. with the Administrator verified the medication pills were left on Resident #17's bedside table in a cup. The Administrator verified no residents were approved to self-administer medication. Review of the facility's list of residents who were cognitively impaired and independently mobile revealed Resident #2, #7, #23, #31, #39, and #207 were cognitively impaired and independently mobile. Review of the facility's policy titled Medication Administration: Self-Administration of Medications, dated November 2017, revealed when determining if self-administration is clinically appropriate for a resident, the interdisciplinary team determines if it is appropriate and is subject to periodic assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident and staff interviews, and review of the facility's guidelines, the facility failed to ensure resident meal preferences were considered and offered. This affected one (#202) of two residents reviewed for choices. The facility census was 61. Findings include: Review of the medical record review revealed Resident #202 initial admission date was 09/09/21 with readmission on [DATE]. Diagnoses included essential (primary) hypertension, chronic kidney disease stage two, atrial fibrillation, anemia and Diabetes Mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/09/21, revealed the resident was cognitively intact. Review of Resident #202's care plan, updated 09/27/21, revealed a focus area of nutritional status with an intervention to honor resident food preferences. Interview on 10/12/21 at 12:19 P.M. with Resident #202 revealed he was not able to choose his own meals or was not offered substitutes. Resident #202 reported he only receives the basic meal because he was at the hospital when the meal tickets with substitute options were provided. Interview on 10/13/21 at 11:02 A.M. with Resident Council Members including Resident #7, #20, #34, #35, #41, and #48 revealed menu meal tickets were received in a bundle seven to fourteen days in advance but as much as four weeks in advance. Interview on 10/13/21 at 12:41 P.M. with Resident #202 revealed he had a burger and French fries for lunch. If he could have chosen something else, he would have. Observation at the same time revealed a blank lunch meal ticket on the meal tray. Interview on 10/13/21 at 12:48 P.M. with State Tested Nursing Assistant (STNA) #313 revealed Resident #202 has a non-select meal ticket meaning he receives the general menu item for the meals. Interview on 10/13/21 at 1:18 P.M. with Dietary #337 revealed resident's were provided meal tickets to order their meal preferences a week in advance. Dietary #337 verified Resident #202 has received a non-selective meal or the general menu item since he returned from the hospital on [DATE]. It was reported only the dietary manager and dietician can print the meal tickets. Dietary #337 stated the dietary manager was not at the facility that week. However, the dietician could print the resident a meal ticket to order an alternative option but she will not be at the facility until 10/15/21. Observation on 10/14/21 at 9:21 A.M. of Resident #202's breakfast meal tray revealed a non-selective or blank breakfast meal ticket. Interview on 10/14/21 at 9:21 A.M. with STNA #334 verified Resident #202 received the non-selective or general breakfast. Review of the Notice to Residents, no date, revealed each day the daily caregiver on the hall will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bring a menu that offers a main entrée and an alternate listed. The resident chooses what they want within the guidelines of their dietary needs. If the two entrees offered do not appeal to the resident, alternates including hamburger, cheeseburger, ham and cheese, grilled cheese, hot dog, peanut butter and jelly, bologna sandwich, fried egg sandwich, cottage cheese and fruit place, chef salad, and soup options are offered. A hand written note on the document stated just because someone is new, do not refuse to give them what they want. Event ID: Facility ID: 365619 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 3. Observation on 10/12/21 at 9:50 A.M. of Resident #12 and Resident #50's shared bathroom revealed a bed sheet folded laying on the floor beside toilet to catch water dripping from a hand held sprayer. Residents Affected - Some Interview and observation on 10/14/21 at 9:05 A.M. with the Director of Maintenance #326 and the Administrator verified the bed sheet was laying on the floor beside the toilet in Resident #12 and #50's shared bathroom. The Director of Maintenance said he was not aware of the dripping faucet. Based on observation, resident and staff interviews, and review of the facility's policy, the facility failed to ensure resident's equipment and environment was maintained in a safe and sanitary manner. This affected four residents (#12, #37, #50, and #208) of 26 residents reviewed for physical environment. The facility census was 61. Findings include: 1. Interview on 10/12/21 at 11:34 A.M. with Resident #37 revealed the resident's bed remote cord was worn and cracked. Resident #37 revealed it was a concern to her and she had previously told unidentified staff. Observation on 10/12/21 at 11:35 A.M. revealed Resident #37's bed remote cord cracked and worn without exposed wires. Interview on 10/14/21 at 9:02 A.M. with the Director of Maintenance #326 revealed on 10/13/21 he had replaced the television in Resident #37's room and it was the first he was aware of the worn and cracked bed remote. Director of Maintenance #326 revealed he has a new remote and he plans on replacing it with. 2. Observation on 10/12/21 at 12:35 P.M. of Resident #208's room revealed directly above the residents head on the ceiling there was a crack about 18 inches to two feet long with a round circle approximately two feet wide. Interview on 10/14/21 at 8:55 A.M. with the Director of Maintenance #326 revealed he was not aware of the damaged ceiling. Director of Maintenance #326 reported it appeared to be old water damage and not currently damp. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 13 of 13