Inspection·February 15, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure call lights were within reach and accessible for two (#12 and #34) residents. In addition, the facility failed to ensure a resident (#6) was provided the opportunity to smoke or the necessary interventions to cease smoking. This affected three (#6, #12 and #34) of 65 residents reviewed for accomodation of needs. The facility census was 65. Residents Affected - Few Findings include: 1. Review of Resident #34's medical record revealed an admission date of 12/12/18, with diagnoses including to diabetes mellitus, dementia, and trigeminal neuralgia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was severely cognitively impaired and required extensive assistance for activities of daily living. Review of the care plan dated 10/19/23 revealed that Resident #34 was at risk for falls with the intervention of call light within reach when in room. Observation on 02/12/24 at 7:22 P.M., of Resident #34 revealed the resident was lying in bed with her eyes open. The call light was noted to be lying on the nightstand approximately eight inches from the bed and out of reach of Resident #34. Interview on 02/12/24 at 7:22 P.M., with Social Service Designee (SSD) #253 verified the call light was out of reach. 3. Review of the medical record for Resident #6 revealed an admission date of 01/15/24. Diagnoses included Alzheimer's, diabetes, dementia, chronic pain, and cognitive deficit. Review of admission assessment dated [DATE] marked resident yes for smoking. Review of the plan of care dated 01/22/24 revealed resident had no care plan for being a resident that smoked. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired with a BIMS of 4 and required supervision or touching assist for ambulation. Review progress notes since admission revealed no mention of issues with resident smoking, staff having issues with resident when smoking or any conversations with resident representative related to resident smoking or concerns related to resident smoking. Interview on 02/13/24 at 9:45 A.M., with Resident #6 revealed she was a smoker. Interview on 02/13/24 at 10:14 A.M., with Licensed Practical Nurse (LPN) #245 stated residents in the memory care unit do not go out to smoke. LPN #245 stated if was her understanding they were not allowed to smoke and also stated Resident #6 had been a smoker prior to her admission. Interview on 02/13/24 at 3:32 P.M., with State Tested Nurse Aide (STNA) #267 revealed residents in memory care do not leave the unit to smoke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 2 of 28 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 02/15/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/13/24 at 4:01 P.M., with LPN #268 revealed no residents were able to smoke in memory care and reviewed Resident #6's orders and confirmed she was never ordered smoking cessation items. Interview on 02/13/24 at 4:39 P.M., with Director of Nursing (DON) revealed Resident #6 was a heavy smoker upon admission and facility had issues with redirection of resident so they spoke with her family/resident representative and he requested she not be allowed to smoke. DON confirmed she was unaware of any issue, concerns, or conversations being documented but would check for information. Interviews on 02/13/24 from 5:00 to 5:30 P.M., with DON confirmed no information was found including safe smoking assessment, care plan for smoking, smoking cessation, and discussions and documentation of safety concerns leading to resident loosing her right to smoke. Review of the policy titled, Resident Smoking, dated 06/08/22, revealed the facility the facility would preserve the resident right to safely smoke unless not medically advisable and documented in the medical record by the attending physician. Residents should be assessed upon admission and quarterly for their ability to safely smoke. A residents particular preferences, problems, concerns, or behaviors pertaining to smoking shall be addressed in the interdisciplinary plan of care. 2. Review of medical record for Resident #12 revealed an admission date of 11/15/23, with diagnoses including: vascular dementia, traumatic subarachnoid hemorrhage without loss of consciousness, major depressive disorder, and generalized anxiety disorder. Review of minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of zero which indicated severe cognitive impairment. Resident #12 required partial to moderate assistance with activities of daily living. Observation on 02/12/24 at 8:58 P.M., revealed Resident #12 laying in bed with call light hanging on the privacy curtain out of reach. Interview on 02/12/24 at 8:58 P.M., with State Tested Nursing Assistant (STNA) #200 verified the call light hanging on privacy curtain and not in reach of the resident. STNA #200 placed the call light in reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 3 of 28 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 02/15/2024 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 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, review of a facility self reported incident (SRI), resident and staff interviews, the facility failed to promote and facilitate a resident to have visitors of their choosing and where they want to meet. This affected one (#8) of 18 sampled for residents rights. The facility census was 65. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 08/24/21, with medical diagnoses including: stroke, schizophrenia, major depression and anemia. Review of the most recent annual assessment dated [DATE], revealed the resident was moderately cognitively impaired. Review of Resident #8's plan of care identified she will visit with her sons in a common area. The record and plan of care identified no reason to require Resident #8 to visit family in a common area. Review of Resident #8's nurse notes dated 02/08/24 at 7:13 P.M., documented two of her children had come to visit. The notes documented Resident #8 did not want to get out of bed as she just got back into bed. The notes documented the children were informed they could not visit and became upset. Review of a facility self reported incident (SRI) dated 09/26/23 identified a staff person witnessed Resident #8's family member moving her in bed. The staff person reported they observed a family member push up on the underside of her breast. Resident #8 denies any inappropriate touching and states that they just helping her move in the bed. The facility completed an investigation and identified the allegation was unsubstantiated. Interview on 02/13/24 at 4:24 P.M., with Resident #8 stated she prefers to visit family when they visit where ever she is located. Resident #8 stated there are times she does not want to get out of bed and it would be nice if her family could visit in her room. Resident #8 stated she has no idea why they are not allowed to do that. Interview on 02/13/24 at 2:17 P.M., with Licensed Practical Nurse (LPN) #251 confirmed Resident #8's sons are only permitted to visit her in a common area and no family is allowed alone with her in her room. LPN #251 confirmed she is not sure of the reason for this and it has upset the family in the past. The interview confirmed there are many days Resident #8 does not want to get out of bed. Interview on 02/14/24 at 10:44 A.M., with the facility Director of Nursing (DON) confirmed Resident #8 does not have a legal guardian and is able to make her needs/wishes known. The interview confirmed there is a current plan of care (POC) that identified the resident agreed to visit her family only in a common area. The interview identified she could not locate any evidence of why this was started and or being continued. This deficiency represents the noncompliance investigated under Compliant Number OH00150625. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 4 of 28 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 02/15/2024 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 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. Based on record review, policy review and staff interview, the facility failed to ensure residents had an accurate code status documented in the medical record. This affected one (#5) of two reviewed for advanced directives. Facility census was 65. Findings include: Review of the medical record for the Resident #5 revealed an admission date of 10/23/18. Diagnoses included diabetes type two, chronic obstructive pulmonary disease, legal blindness, and muscle weakness. Review of a paper/ hard chart revealed physician order dated 10/24/18 revealed an order for full code. Review of the paper (hard copy) medical record revealed a code status of full code with a bright colored paper Review of the electronic medical record revealed a code status of DNRCC-A (do not resuscitate comfort care arrest) Interview on 02/13/24 at 10:30 A.M., with Licensed Practical Nurse (LPN) #269 and Director of Nursing (DON) confirmed code status did not match between the electronic and paper medical record. They revealed the paper chart had full code orders and colored directive and the electronic record had a code status of DNRCC-A. Review of the policy titled, Do Not Resuscitate Order, dated 11/30/23 revealed the facility's interdisciplinary care planning team shall review advanced directives with the resident and family during quarterly care planning. Facility shall review DNRCC and DNRCC-A form would be completed upon admission and quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 5 of 28 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 02/15/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, self reported incident review, and staff interview, the facility failed to ensure a complete and thorough investigation was completed into an allegation of physical abuse alleged. In addition the facility failed ot provide protection for residents agianst the alleged abuser. This had the potential to affect all 65 residents in the facility. The facility census was 65. Residents Affected - Many Findings include: Review of Resident #176's medical record revealed an admission date of 11/09/23 and a discharge date of 12/12/23. Diagnoses included myoneural disorder, major depressive disorder, and dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #176 was severely cognitively impaired and was dependent on activities of daily living (ADL). Review of facility self-reported incident (SRI) tracking number 241433 filed on 11/22/23 revealed Resident #176 alleged that a male staff member pushed his face into a pillow. Resident #176 reported the allegation to his family, then the family reported it to the facility. In a follow up interview later in the day, Resident #176 gave a different story and denied the incident. The facility unsubstantiated the allegation of abuse. Review of the facility investigation revealed as a result of the investigation we (the facility) interviewed the residents on the unit. They all felt safe, that their needs were being met, and they did not have any concerns regarding the staff. There was no documentation noted to indicate the date or who interviewed the residents. Further review of the investigation revealed the male staff member was not suspended during the investigation. Interview on 02/15/24 at 2:18 P.M., with The Administrator and Director of Nursing (DON) revealed the male State Tested Nursing Assistant (STNA) was not suspended during the investigation because the family did not believe the incident to be true. Administrator stated that the family did not want a police report and that Resident #176 talked about a menstrual cycle that day. Administrator stated they did an SRI because of due diligence and didn't feel the male STNA should have been suspended because their investigation showed that he didn't do anything wrong. DON stated she is the person that interviewed the residents on the day of the incident even though there was no date, time or signature on the documentation presented. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 11/30/23, revealed when a staff member is accused of abuse, neglect, exploitation, or misappropriation of resident property, the facility should immediately remove staff member from facility and schedule pending the outcome of the investigation. Evidence of the investigation should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 6 of 28 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 02/15/2024 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 0641 Ensure each resident receives an accurate assessment. 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, review of the Resident Assessment Instrument (RAI) manual and staff interview, the facility failed to ensure the Minimum Data Sets (MDS) and fall risk assessments were completed accurately. This affected three (#8, #29, #68) of 18 sampled residents assessments reviewed. The facility census was 65. Residents Affected - Few Findings include: 1. Review of Resident #29's medical record revealed an admission date of 10/06/22. Review of the annual MDS dated [DATE] under section K; identified Resident #29 had significant weight loss of 5% or more in the last month or loss of 10% in the last 6 months. Review of Resident #29's weights in the previous 6 months revealed on 05/01/23 her weight was 216 and on 10/01/23 a weight of 229 pounds. This was a 5.68% weight gain over that time period. 2. Review of Resident #68's medical record revealed admission date of 12/13/23. The admission MDS dated [DATE] identified under section K significant weight loss. Resident #68's weight records identified an admission weight of 246 pounds. The record identified the next weight was listed on 12/18/23 at 227 pounds. The record identified a weight dated 12/28/23 of 249 pounds. Review of the initial nutritional assessment dated [DATE] identified Resident #68 is a new admission with a weight os 246 pounds. The assessment identified the weight on 12/18/23 was 227 pounds and revealed a possible discrepancy in weight. The records identified no clarification weight was completed until 12/28/23 which confirmed no significant weight loss. Interview on 02/13/24 at 8:02 A.M., with the MDS Registered Nurse (RN ) #247 revealed Resident #29 and Resident #68's MDS assessments for significant weight loss were not accurate. The interview confirmed Resident #29 and #68 did not have significant weight loss. 3. Review of Resident #8's medical record revealed an admission date of 08/24/21, with medical diagnosis including stroke, schizophrenia and major depression. Review of Resident #8's MDS dated [DATE] and 01/20/24, under section B identified vision with no corrective lenses. The record identified no plans of care related to Resident #8's vision. Review of a vision consult note dated 07/18/23 identified Resident #8 was noted with Bifocal glasses. Interview on 02/14/24 at 10:24 A.M., with STNA #216 confirmed Resident #8 received glasses's on 11/22/22 and had a vision exam with those glasses on 07/18/23. The interview confirmed she was not aware of Resident #8's missing glasses. STNA #216 confirmed she is responsible for setting up appointments for residents. Review of Resident #8's quarterly fall risk assessment dated [DATE] was completed. The assessment identified under the question did the resident fall in the past 90 days. The assessment identified no falls in the past 90 days. Review of Resident #8's nursing notes dated 08/25/23 revealed Resident #8 was found on the floor on her knees and did not know how she rolled out of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 7 of 28 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 02/15/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Interview on 02/14/24 at 2:15 P.M., with with LPN #229 verified the fall quarterly assessment dated [DATE], is not accurate to identified the fall that occurred on 08/25/23. Interview on 02/14/23 at 10:59 A.M., with MDS/RN #247 verified she was no aware Resident #8 had glasses and she never had them on when she was interviewed. Residents Affected - Few Review of the Resident Assessment Instrument (RAI) (MDS) manual identified the instructions for section B-1200 Corrective Lenses revealed the steps for assessments included; Check the medical record for evidence that the resident used corrective lenses when ability to see was recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 8 of 28 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 02/15/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to ensure pre-admission screening and resident review (PASARR) were completed accurately and corrected as needed. This affected two (#7 and #13) of two residents reviewed for PASARR. Facility census was 65. Findings include 1. Review of the medical record for the Resident #7 revealed an admission date of 09/30/21. Diagnoses included paranoid schizophrenia, diabetes, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact with a BIMS of 15 and required assistance for ambulation and activities of daily living. Review of the PASARR dated 11/07/21 revealed only mood disorder was documented. 2. Review of the medical record for the Resident #13 revealed an admission date of 11/19/18. Diagnoses included chronic obstructive pulmonary disease, diabetes type two, heart failure, anxiety, bipolar disorder, and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact with a BIMS of 15. Review of the PASARR dated 11/19/18 revealed only schizophrenia and panic/anxiety was documented. Interview on 02/14/24 at 9:36 A.M. with Social Services Designee #253 confirmed facility had a procedure where a corporate staffer sends her a list of PASARR's that need updated or completed and confirmed Resident #7 and #13 were not listed for updated PASARR's. She revealed Resident #7 had an incorrect last name and not all of her diagnoses were listed (missing paranoid schizophrenia and anxiety) and Resident #13's diagnoses was missing the bipolar diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 9 of 28 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 02/15/2024 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 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 record review and staff interview, the facility failed to update care plans regarding elopement and advanced directives. This affected one (#25) of 18 sampled residents care plans reviewed. The facility census was 65. Findings include: Review of medical record for Resident #25 revealed an admission date of 12/13/23, with diagnoses including dementia with agitation, Alzheimer's disease, epileptic seizures, altered mental status, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of zero which indicated severely cognitively impaired. No behaviors noted during the look back period. Review of Care Plan dated 02/02/24 revealed resident/family had chosen advanced directive of Full Code. Review of care plan revealed Resident #25 wanders aimlessly/elopement risk related to impaired safety awareness, dementia. Interventions include wander guard to right ankle, check placement per protocol. Review of physician orders for Resident #25 revealed code status of Do Not Resuscitate Comfort Care (DNRCC). No order noted for wander guard. Wander guard noted to be discontinued on 01/04/24. Observation on 02/14/24 at 10:36 A.M., of Resident #25 revealed no wander guard to right ankle or left ankle. Interview on 02/14/24 at 9:51 A.M., with Director of Nursing (DON) verified the facility completed an audit on 02/13/24 of care plans and updated them as needed. DON verified that code status care plan was initiated as DNRCC on 02/13/24 and was Full Code prior to that. Interview on 02/14/24 at 11:25 A.M., with DON verified that no active order noted in Point Click Care (PCC) for wander guard. DON verified wander guard was discontinued. DON verified the wander guard was still in the intervention section of the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 10 of 28 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 02/15/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #8's medical record revealed an admission date of 08/24/21, with diagnoses of stroke, schizophrenia, major depression and anemia. Residents Affected - Some Review of Resident #8's activities plan of care identified she enjoys cards, games (rummy and Bingo) art/crafts, coloring, computer/tablet games, cooking, country music, religious involvement, travel, outings, movies, parties and socials events. The plan identified she needs assistance to and from activities. Observations on 02/12/24 at 7:41 P.M. and 02/13/23 at 11:25 A.M., revealed Resident #8 was awake and staring at the television in the room. Resident #8's room was observed to have no independent items in the room to do activities. The room had no games, coloring books and or radio to enjoy her identified preferred activities. Review of the facility's activity calendar dated 02/13/24 identified at 2:00 P.M., for a Mardi gras party. Observation on 02/13/24 at 2:05 P.M., revealed Resident #8 was in bed. Resident #8 was asked if she would like to attend the party and she responded what party and yes I would certainly like to get up and go to the party. Interview on 02/13/24 at 2:08 P.M., with Stated Tested Nursing Assistant (STNA) #235 revealed Resident #8 had expressed she would like to attend the activity. STNA #235 proceeded to get Resident #8 out of bed and took her to the party. Observation on 02/13/24 at 2:20 P.M., identified Resident #8 was in the activity and was interacting with multiple other residents, laughing and smiling. Based on observations, medical record review, activity calendar review, census review, resident interviews, and staff interviews, the facility failed to ensure residents were offer or assisted in attending activities. This affected three Residents (#6 and #21) from the memory care unit and Resident #8 from a non-memory care unit, but also had the potential to effect all 13 Residents in the memory care unit (#4, #6, #12, #15, #21, #22, #25, #26, #37, #50, #63, #272, and #273). Facility census was 65. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/15/24. Diagnoses included Alzheimer's, diabetes, dementia, chronic pain, and cognitive deficit. Review of Resident #6's recreation admission assessment dated [DATE] revealed the resident is interested in listening to music, being around animals, keeping up with the news, doing group activities. Resident family reported activities were very important for resident. Review of the plan of care dated 01/22/24 revealed the resident was at risk for decreased activity participation with interventions to assist in arranging activities, assure activities the resident attends were compatible with physical and mental capabilities, encourage attendance and participation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 11 of 28 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 02/15/2024 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 and invite to activities of interest. Level of Harm - Minimal harm or potential for actual harm Review progress notes dated 01/22/24 revealed the resident was alert and oriented and POA was contacted for information about the resident. The note stated activities staff would provide independent leisure activity supplies, room visits and activity staff would transfer resident to and from activities. Residents Affected - Some Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired and required supervision or touching assist for ambulation. Review of progress note dated 02/14/24 revealed the resident participated in snack and music. No other documentation in notes related to participation in activities. Review of the activity attendance dated 01/18/24 to 02/15/24, revealed the resident was at a music activity on 02/13/24 in the afternoon. Resident was also documented to have attended a social event and special program on 02/13/24 in the afternoon. Observation on 02/13/24 at 9:25 A.M., of the memory care unit revealed the television was playing in the common area with two residents watching, and one laying on the couch asleep. The remaining residents were in their rooms. Resident #6 was not observed participating in any activities. Record review and observation on 02/13/24 at 9:36 A.M., of the activity calendar revealed for this date (02/13/24) activities included 9:30 A.M. music instrumental; 10:00 A.M. snack; 11:00 A.M. music; 12:00 P.M. lunch; 1:00 P.M. photo fun; 2:00 P.M. snack; and 3:00 P.M. Becky's music. Observation at this time, (9:36 A.M.) revealed no music was playing and no residents were doing anything music related. The television was playing in the common area. Observation and interview on 02/13/24 from 10:08 A.M. to 10:11 A.M., revealed no residents were in the common area for snacks at this time. State Tested Nursing Aide (STNA) #267 was sitting at table with one resident. STNA #267 stated they try to get resident to color do crafts or puzzles and verified no music activity was being done this date at 9:30 A.M. and no snack at 10:00 A.M. Observation and interview on 02/13/24 at 3:20 P.M., revealed Resident #6 was in the memory care unit. There was no group music activity (Becky's music) occurring in the memory care unit. STNA #267 confirmed Resident #6 was not at the group activity in the main dining room. Review of the facility census record revealed 13 (#4, #6, #12, #15, #21, #22, #25, #26, #37, #50, #63, #272, and #273) residents resided on the memory care unit. Interview on 02/15/24 at 11:25 A.M., with Activity Director (AD) #213 revealed activities should be documented for attendance. Interview on 02/15/24 at 1:28 P.M., with Activity Director (AD) #213 confirmed Resident #6 did not attend the music activity 02/13/24 afternoon and confirmed this was marked in error. AD #213 revealed the activity assistance had left the facility and she was responsible to supervise residents while at the activity. AD #213 revealed she was unable to supervise residents in the common area and unless resident families brought them to the activity, residents on memory care would not be invited or able to attend group activities in the dinning room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 12 of 28 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 02/15/2024 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 - Some 3. Review of medical record for Resident #21 revealed admission date of 09/05/23, with diagnoses including Alzheimer's disease, dementia with agitation, depression, and insomnia. The resident resided on the memory care unit. Review of Minimum Data Set (MDS) dated [DATE] revealed the resident was assessed as having severe cognitive impairment, no behaviors noted during the look back period and required setup or clean-up assistance for activities of daily living. Review of care plan dated 12/11/23 for Resident #21 revealed potential for decreased activity participation, involvement and/or social isolation related to impaired decision making. Interventions included but not limited to provide a calendar of scheduled activities, provide assistance/escort activity functions, provide one on one bedside/in-room visits and activities if unable to attend out of room, invite to activities of interest, invite to attend scheduled activities, explain to importance of social interaction, leisure activity time, and encourage attendance and participation in activities. Review of memory care activity calendar revealed for 02/13/24 revealed 9:30 A.M. music, 10:00 A.M. snack, 11:00 A.M. music, 12:00 P.M. lunch, 1:00 P.M. photo fun, 2:00 P.M. snack, and 3:00 P.M. Becky's music. Review of main facility activity calendar for 02/13/24 revealed the only activity that matched the memory care activity calendar was the 3:00 P.M. Becky's music. Further review revealed the calendars did not match for the rest of the month as well. Observation on 02/13/24 at 9:25 A.M., revealed television playing in the common area with two residents watching and one laying on the couch asleep. No one on one activities being completed. A State Tested Nursing Assistant (STNA) observed at the table in the unit. Observation on 02/13/24 at 9:36 A.M., revealed no music playing in memory care unit. Television observed to be on in common area. No activity staff observed in the unit asking if residents want to attend activities. No one on one visits observed. Observation on 02/13/24 at 10:08 A.M., revealed no residents in the common area for snacks. A STNA sitting at a table with a resident. Other residents observed in their rooms. Same three residents observed in the common area with the television on. One of the residents sleeping on the couch and another sleeping on and off in recliner. No activities staff noted on unit at this time. Observation on 02/13/24 at 2:33 P.M., revealed residents up in common/dining area in memory care unit. Residents getting coffee/juice in dining area. No activities staff on the unit asking if residents want to attend activity. No one on one activities observed being completed. Observation 02/13/24 at 3:00 P.M., revealed no resident observed going to an activity until this time with Resident #21 going to music activity in main dining area with her husband. No activities staff observed going into unit to ask residents if they wanted to attend activities offered prior to 3:00 P.M. No activities observed being completed with residents throughout the day by staff on the unit besides television. No one on one activities observed being completed on the unit today. Observation on 02/13/24 at 3:14 P.M., revealed residents up in dining/common area. No music activity being held at this time per the schedule. STNA sitting at the table with residents and not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 13 of 28 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 02/15/2024 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 engaging residents in activity of any sort. One resident walking around in hallway with walker. Level of Harm - Minimal harm or potential for actual harm Observation on 02/13/24 at 4:43 P.M., revealed residents up in common area/dining area in unit conversing amongst themselves. Television program playing which was Toy Story. Residents Affected - Some Observation on 02/14/24 at 8:57 A.M., revealed five residents up in common/dining area. Two residents sitting in recliners sleeping in TV area with TV game show on. Observation on 02/14/24 at 9:36 A.M., revealed four residents in the common/dining area including Resident #21. No residents observed playing ring toss nor is the ring toss game out at this time. One resident observed sleeping in a recliner. Interview on 02/13/24 at 9:24 A.M., with Resident #21 reported they do not do activities such as bingo, cards, or coloring. Interview on 02/13/24 at 10:11 A.M., with STNA #228 verified no music was completed at 9:30 A.M. or snack given at 10:00 A.M. on the memory care unit per the calendar schedule. STNA #228 reported that the activity staff come down to complete what is on the calendar. Interview on 02/13/24 at 3:00 P.M., with STNA #228 and STNA #246 reported that the activity calendar posted on the memory care unit was the main calendar for the facility. Both reported that Resident #21 attended the music activity with her husband. Both verified that no music was playing in the unit per the calendar. Interview on 02/14/24 at 9:41 A.M., with Resident #21 verified she did not play ring toss this morning. Resident #21 denied any staff asking if she wanted to play. Review of the calendar for the memory care unit and the calendar for the rest of the facility revealed the calendars do not match in activities except for the Becky's music at 3:00 P.M. on 02/13/24. All other activities are different and at different times. Calendar activities should be completed in the unit with the residents. The 02/14/24 activities should include 9:30 A.M. ring toss; 10 A.M., snack, 11 A.M. music, 12 P.M. lunch, 1 P.M. finger painting, 2 P.M. snack, 3 P.M. reminiscing, 4 P.M. bingo, and 5 P.M., evening wind down. This deficiency represents the noncompliance investigated under Compliant Number OH00150625. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 14 of 28 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 02/15/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, resident and staff interviews, the facility failed to ensure a resident was provided the necessary glasses to maintain vision. In addition, ensure a system was in place for staff to identify which resident requires assistive devices. This affected one (#8) of 18 sampled residents. The facility census was 65. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 08/24/21, with medical diagnoses including: stroke, schizophrenia and major depression. Review of Resident #8's Minimal Data Set (MDS) assessment dated [DATE] and 01/20/24, under section B identified vision with no corrective lenses. The record identified no plans of care related to Resident #8's vision/glasses. Interview and observation on 02/12/24 at 7:41 A.M., revealed Resident #8 stated she has glasses but does not know where they are. Resident #8's room was observed with an empty glass case. Review of a vision consult note dated 07/18/23, identified Resident #8 was noted with Bifocal glasses. Interview on 02/13/24 at 2:13 P.M., with State Tested Nursing Assistant (STNA) #235 when asked how she identified if residents have glasses, dentures and or hearing aides; STNA #235 confirmed she is not sure how to locate any of that information. Interview on 02/13/24 at 1:45 P.M., with STNA #222 when asked how the staff are aware of residents that have glasses, dentures and or hearing aides; STNA #222 identified she is not really sure. Interview on 02/13/24 at 2:17 P.M., with Licensed Practical Nurse (LPN) #251 when asked if Resident #8 had glasses; LPN #251 confirmed she is not sure if the resident has glasses or not. Interview on 02/14/24 at 10:24 A.M., with STNA #216 confirmed Resident #8 received glasses's on 11/22/22 and had a vision exam with those glasses on 07/18/23. The interview confirmed she was not aware of Resident #8's missing glasses. STNA #216 confirmed she is responsible for setting up appointments for residents. Interview and observation on 02/13/24 at 2:58 P.M., with the Director of Nursing (DON) when asked where nursing assistants can locate information if residents need glasses, dentures and or hearing aides. The DON identified there are [NAME] books with that information located in each units shower room. Observation of the shower room for unit C confirmed the book could not be located and was not provided during the survey. Interview on 02/14/23 at 10:59 A.M., with MDS/Registered Nurse (RN) #247 confirmed she was not aware Resident #8 had glasses and she never had them on when she was interviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 15 of 28 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 02/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, policy reviews, and staff interviews, the facility failed to ensure a resident was accurately assessed after an elopement attempted, ensure staff was informed to monitor resident after an elopement attempt, and a resident's fall interventions were implemented. This affected two (#15 and #46) of two residents reviewed for accidents and hazards. Facility census was 65. Findings include 1. Review of the medical record for the Resident #46 revealed an admission date of [DATE]. Diagnoses included: chronic obstructive pulmonary disease, diabetes, respiratory failure, and muscle weakness and cognitive communication deficit. Review of admission elopement assessment dated [DATE] revealed resident had no cognitive impairment or poor decision making skills, no diagnosis of dementia, did not ambulate independently, resident without desire to go home, no history of elopement or exit seeking behavior, resident did not wander aimlessly, and resident was not wandering or exit seeking to find family. No new assessment was completed after elopement attempt on [DATE]. Review of the plan of care dated [DATE] revealed no care plan for wandering. A care plan was initiated on [DATE] to distract resident from wandering and document any wandering behaviors. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively impaired and was independent with supervision for mobility. Review of physician orders reviewed from [DATE] to [DATE] found no evidence of interventions related to elopement. Review progress notes dated [DATE], revealed the resident tried to elope out the front door. This nurse went to get her and when asking her where she was trying to go she stated to find my parents. This nurse tried to reorient her to where she was and day and time. Staff then contacted resident's family who reported resident had increased confusion and they felt her dementia was getting worse and wanted to see about resident moving to the memory care unit. Further review of the medical record revealed no evidence of additional notes or documentation related to a change in resident status and how staff were to monitor after an elopement attempt. Review of undated physician note undated (facility DON reported it was from visit on [DATE]) revealed nursing stated she had been exit seeking. Observations on [DATE] from 10:00 A.M. to 4:30 P.M., revealed several observations of Resident #46 sitting in her wheelchair in the lobby and near the nurses station. She was seen several times asking staff to find her parents and asked staff to call her parents (both parents are deceased ). Staff were not contacting her parents and informed the resident they would try later. Resident was able to self-propel in her wheelchair using her feet independently. Interview and observation on [DATE] at 4:01 P.M., with LPN #268 revealed being unaware of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 16 of 28 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 02/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm #46 having attempted to elope. LPN #268 revealed being unaware of any new interventions or monitoring that was being completed. LPN #268 asked the three additional staff (nurses and aides) at the nurses station if they had heard of an elopement attempt and any new interventions or monitoring and all three stated no. LPN #268 confirmed no information had been provided related to monitoring of Resident #46 for elopement. Residents Affected - Few Interview on [DATE] at 4:39 P.M., with Director of Nursing (DON) revealed a progress note stated Resident #46 had an elopement attempt and revealed the facility had updated elopement assessment. DON stated the elopement assessment was still accurate as Resident did not elope. Assessment was reviewed and DON would not confirm the following questions were not still accurate including: no cognitive impairment or poor decision-making skills, did not ambulate independently, resident without desire to go home, no history of elopement or exit seeking behavior, and resident was not wandering or exit seeking to find family. DON revealed the facility had looked at moving her to dementia unit at family request, but due to facility not having a diagnosis of dementia, they could not transfer her. She revealed they were waiting on family to bring in a note stating she had dementia. The DON stated the facility physician could put in a diagnosis of dementia, if they wanted to but was unsure what the plan was. DON stated a care plan was put in place on [DATE] to monitor and had no response when asked why staff interviewed and additional staff at the nursing station had no knowledge of any incident or that resident should be monitored for exit seeking and wandering. The facility was unable to provide any additional evidence of staff knowledge or monitoring after an elopement attempt Review of the policy titled, Code [NAME] - Elopement and Wandering Prevention, dated [DATE], revealed the facility prevention from wandering and elopement, was all residents upon admission would have an elopement risk assessment completed and the assessment would be updated quarterly and PRN (as needed) by the interdisciplinary care team and if indicated interventions would be put in place. 2. Review of medical record for Resident #15 revealed an admission date of [DATE], with diagnoses including dementia, obesity, stenosis of coronary artery stent, depression, altered mental status, repeated falls, and adult failure to thrive. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as having severe cognitive impairment, no behaviors were noted during look back period, and required partial to moderate assistance for activities of daily living. Review of monthly physician orders for February 2024 revealed an order for non skid floor mat next to the right side of bed while in bed. Review of care plan revealed fall interventions included call light accessible when in room, non slip footwear, pillows at edge of bed to help define edges and assist with positioning as tolerated, and protective floor mat next to bed. Observation on [DATE] at 9:40 A.M., revealed the resident lying in bed with no floor mat observed beside the bed. The floor mat observed leaning against the wall in Resident #15's room. Interview on [DATE] at 9:46 A.M., with Licensed Practical Nurse (LPN) #229 verified floor mat was not beside the bed as ordered. LPN #229 verified floor mat should be beside the bed anytime the resident is in bed. LPN #229 then placed the floor mat beside the bed. Review of policy titled, Falls-Clinical Protocol dated [DATE], revealed staff and physician will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 17 of 28 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 02/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm identify pertinent interventions to try to prevent subsequent falls and to address the risks of serious consequences of falling. This deficiency represents the noncompliance investigated under Compliant Number OH00150625. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 18 of 28 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 02/15/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, dietary meal cards review, and staff interviews, the facility failed to ensure a physician ordered fluids restriction was being provided as ordered. This affected one (#40) of one resident identified with fluid restriction. The facility census was 65. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed admission date on 12/21/23, with medical diagnoses including pneumonia, end stage renal disease, fractured 5th lumbar vertebra, major depression and hyperkalemia. Review of physician orders dated 12/27/23, identified a fluid restriction for the resident that included: fluid restriction of 1500 ml (milliliter) daily divided 540 ml for nursing and 960 ml for dietary and no water pitcher at the bedside. Review of Resident #40's nutritional assessment dated [DATE] revealed the resident was a new resident at the facility. The assessment identified Resident #40 was on a 1500 ml fluid restriction and is able to feed himself. The notes identified Dietician #264 spoke with Resident #40's dialysis center and confirmed the need for the fluid restriction of 1500 ml. The notes identified she put in the physician order, updated task and tray card. Observation on 02/13/23 at 7:44 A.M., of the breakfast meal for Resident #40 revealed staff were observed to provide a 8 ounce carton of milk, a 6 ounce cup of apple juice and 6 ounces cup of coffee for a total of 600 ml on the meal tray. Resident #40's over the bed table was also observed with 12 ounce (360 ml) Styrofoam cup of water with a straw. Review of the meal ticket located on the meal tray was completed. The meal ticket did not identify Resident #40 had a fluid restriction. Observation on 02/14/24 at 7:19 A.M., of Resident #40 revealed a full 12 ounce (360 ml) Styrofoam cup of water with a straw. On 02/14/24 at 7:31 A.M., Resident #40 was provided his breakfast tray which included a carton of milk that is listed for 8 ounces, 6 ounces of apple juice and 6 ounces of coffee. Interview on 02/14/24 at 8:01 A.M., with Kitchen Staff Member #244 and Dietary Manager #203, revealed the staff were asked if they currently had any residents on a fluid restriction and they both identified NO. Kitchen staff member #244 was the person who was tasked with placing fluids on the meal trays. Dietary Manager #203 was asked how the staff would be aware if a person should be on a fluid restriction and she grabbed a meal ticket and identified it would be listed on the top of the ticket. Interview with the facility Director of Nursing (DON) and Dietary manager #203 was completed on 02/14/24 at 8:14 A.M. The interview confirmed Resident #40's fluid restriction is not accurately listed on the meal ticket and the kitchen staff are no sending the accurate fluids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 19 of 28 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 02/15/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations and staff interviews, the facility failed to ensure the correct posted staffing was completed daily. This had the potential to affect all 65 residents. The facility census was 65. Residents Affected - Many Findings include: Observation of the facility occurred on 02/12/24 at 6:08 P.M., upon entering to start the annual inspection, the posted staffing was observed to be in a plastic frame sitting on the nursing station. The posted staffing was dated 01/31/24. Interview on 02/13/24 at 10:32 A.M., with the Administrator confirmed the posted staffing was dated 01/31/24 on 02/12/24. The interview identified the Central Supply/ Scheduler #201 is responsible for posted daily staffing. Interview on 02/13/24 at 10:35 A.M., with Central Supply/ Scheduler #201 identified she completes the forms for the posted staffing and leaves them in a folder for the night shift nurses to post. The interview confirmed she was not checking if night shift was posting the staffing and confirmed apparently they are not. The interview confirmed the facility is utilizing agency staffing for nursing quite a bit on night shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 20 of 28 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 02/15/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview, and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This potentially affected nine residents, eight who were prescribed puree diets (#8, #12, #28, #40, #44, #58, #65 and #224) and one resident (#59) who was prescribed meat must be pureed. The census was 65. Findings include: Interview on 02/13/24 at 11:09 A.M., with Dietary Manager (DM) #203 revealed the kitchen used premade molds for most food items but on 12/14/24 they will puree a cold ham sandwich for the lunch meal. Observation of puree preparation on 12/14/24 at 10:50 A.M., revealed [NAME] #209 pureed ham salad for lunch. Taste test revealed that the pureed ham had small pieces of ham in it. DM #203 tasted the pureed ham salad and told [NAME] #209 to puree the meat more. [NAME] #209 pureed the ham salad more and pieces of the rind that were found. Pureed ham was at proper consistency prior to service at 11:15 A.M. Review of the policy titled Diet and Nutrition Care Manual- Dysphagia Puree (Level 1) Diet, dated 2015, revealed all pureed foods should be mix a smooth consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 21 of 28 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 02/15/2024 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 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 observations, staff interview, record review, policy review, and staff interview, the facility failed to ensure dishes and utensils were sanitized properly. This had the potential to affect 64 residents that received meals from the facility. One resident (#1) of 65 residents received nothing by mouth. The census was 65. Findings include: Observation on 02/14/24 at 10:30 A.M., of the high temperature dish machine with Dietary Manager (DM) #203 revealed the dish machine registered 158 degrees Fahrenheit (F) for the wash cycle and 178 degrees F for the final rinse. Interviews with Dietary Aide (DA) #244, at the time of the observation, stated she had never seen the final rinse dish machine temperature at 180 degrees F. The temperatures were verified by DM #203 at the time of observation. Observation on 02/14/24 at 3:55 P.M., dish machine was at proper temperature for the final rinse. Review of the dish machine log for February 2024 revealed that the final rinse temperature for the dish machine was not at the required 180 degrees F for 02/12/24 and 02/13/24. Review of the facility infection control logs revealed no food borne illness have been identified. Review of the policy titled, Policy and Procedure Manual-Resource: Sanitation of Dishes/Dish Machine, dated 2023, revealed the final rinse or sanitization should be 180 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 22 of 28 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 02/15/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on medical record review, policy review, fire department run sheet review, resident and staff interviews, the facility failed to document accurate pertinent changes that occurred in Resident #69 condition. This affected one (#69) of 18 sampled residents. The facility census is 65. Findings include: Review of Resident #69's medical record revealed an admission date of [DATE], with a diagnoses of cellulitis of left limb, unspecified convulsions, conversion disorder with seizures or convulsions, and is a full code. Review of the most recent admission assessment dated [DATE] revealed Resident #69 was cognitively intact and requires a staff assist of one person for activities of daily living. Review of progress note dated [DATE] (no time) revealed Resident #69 was found in the restroom sitting on the toilet fully clothed. Resident #69 began jerking, yet his arms and legs were limp. Vital signs were taken. Resident #69 went limp in Licensed Practical Nurse (LPN) #266's arms, and Resident #69's head fell forward. Resident #69 is a full code, and he was lowered to the floor, LPN #266 pushed on Resident #69's chest for a sternal rub. Resident #69 opened his eyes and took a breath, then leaned on his left side and began jerking again. LPN #266 reassured Resident #69, that Emergency Medical Service (EMS) was on the way. EMS arrived, loaded Resident #69 onto a cot and transported him to the Emergency Room. Interview on [DATE] at 11:27 A.M., with Resident #69 stated the nurse had given him his medications and had asked him if he was alright. Resident #69 stated he was crabby towards her, next thing he thought was that he was in his bed. Resident #69 stated his roommate had turned on his light and found Resident #69 in the bathroom; slumped over on the toilet fully dressed, and got the aide. The aide had gotten the nurse, who at that time, Resident #69 was unsure who the nurse was, and he heard something regarding the nurse doing chest compressions and he now has five cracked ribs. Interview on [DATE] at 8:44 A.M., with Clinical Quality Assessment Nurse (QA Nurse) #263 revealed Resident #69 was sent to the hospital on [DATE] due to chest pain and was admitted to the hospital with five fractured ribs. QA Nurse #263 further stated she was unsure how Resident #69 had five fractured ribs and said maybe the hospital or Emergency Medical Technician (EMT)'s performed Cardio Pulmonary Resuscitation (CPR) on Resident #69. Interview on [DATE] at 8:47 A.M., with DON #258 revealed Resident #69 was sent to the hospital on [DATE] as he was having a seizure and became unresponsive and was a full code. DON #258 further stated Resident #69 only received a sternal rub from LPN #266 but did not receive any chest compressions. Review of Progress Note dated [DATE], revealed the hospital called the facility and spoke to LPN #266 advising her that Resident #69 was going to be admitted due to having five fractured ribs from CPR being performed. Review of Discharge summary dated [DATE], stated Resident #69 presented to the Emergency Department after being found unresponsive. Staff reported he started shaking and slumped forward. He did not hit his head. Staff were unable to find a pulse and began CPR. Patient did respond after a few minutes of CPR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 23 of 28 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 02/15/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Bucyrus Fire Department Narrative dated [DATE] states nurse stated she had just given him his medication shortly before this occurred. Nurse found that he had not hit his head nor had any recent falls. The nurse stated she started compressions after he went limp. Interview on [DATE] at 2:10 P.M., with DON #258 stated, from what was charted in the the EMT Narrative dated [DATE], along with the hospital Discharge summary dated [DATE]. DON #258 confirmed there was a discrepancy in the progress note dated [DATE]. Review of policy titled Change in a Resident's Condition dated [DATE], revealed the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 24 of 28 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 02/15/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, Centers for Disease Control Prevention (CDC) guideline review, policy review and staff interview, the facility failed to ensure residents were offered vaccinations and provided education on vaccinations. This affected two (#8 and #15) for influenza (flu) vaccines and one (#13) for pneumococcal (pneumonia) vaccines of five residents reviewed for vaccines. Findings census was 65. Residents Affected - Some Findings include 1. Review of the medical record for Resident #8 revealed an admission date of 08/24/21. Diagnoses included stroke, hepatic failure, diabetes, schizophrenia, depressions and anemia. Review of the vaccination records revealed no evidence of the flu vaccinations being offered, refused or accepted for the 2023 flu season. Chart review also revealed no evidence that education was provided in relation to risks and benefits of receiving the flu vaccine. 2. Review of the medical record for Resident #15 revealed an admission date of 09/12/23. Diagnoses included dementia, obesity, stenosis of coronary artery, altered mental status and failure to thrive. Review of the vaccination records revealed no evidence of the flu vaccinations being offered, refused or accepted. Chart review also revealed no evidence that education was provided in relation to risks and benefits of receiving the flu vaccine. 3. Review of the medical record for the Resident #13 revealed an admission date of 11/19/18. Diagnoses included chronic obstructive pulmonary disease, diabetes type two, heart failure, anxiety, bipolar disorder, and paranoid schizophrenia. Review of the vaccination records revealed Resident #13 received the following pneumonia vaccines: Pneumovax 01/10/17 and Prevnar 13 dated 05/01/21. Facility had no evidence of the pneumonia vaccinations being offered, refused or accepted since 2021. Chart review also revealed no evidence that education was provided in relation to risks and benefits of receiving the pneumonia vaccine. Review of CDC Pneumococcal Vaccine Recommendations dated 09/12/23 revealed Resident #13 should receive one dose of PCV20 at least one year after PCV13 or should receive PPSV23 at least one year after PCV13 and then review again after Resident #13 turned age [AGE]. Interview on 02/14/24 at 2:39 P.M., with Director of Nursing revealed dates should be documented and education boxes can be checked when staff enter the vaccination information. After review of several vaccines revealed some dates were not being shown to show evidence of vaccines being offered, declined, or accepted and also DON confirmed no evidence of education was completed. DON revealed facility documents immunizations under the immunizations tab and reported this information would not be in any other documentation source such as a progress note. Interview on 02/14/24 at 2:50 P.M., with Clinical Corporate RN #263 confirmed facility did not have a way to show education had been provided related to vaccinations. Interview on 02/14/24 at 3:11 P.M., with Medical Records (MR) #216 revealed they had a few consent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 25 of 28 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 02/15/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some signed for flu vaccinations. Upon review they were all signed by the previous Assistant Director of Nursing (ADON) on behalf of the resident as verbal authorizations and none of the forms stated if resident or resident representative had been consented. MR #216 was unable to explain why the ADON would sign a consent for an alert and oriented residents and also confirmed the paperwork did not show evidence it had been discussed or provided to any residents as a staff member signed and dated them all herself without any resident acknowledgement. None of the selected sample residents were included in the consents provided. Review of the policy titled, Influenza Vaccination of Residents, dated 06/08/22, revealed the facility shall offer immunizations against influenza. Residents shall be encouraged to have the vaccine and resident or resident representative would be educated about the risk and benefit of the influenza on an annual basis. Review of the policy titled, Pneumococcal Vaccination of Residents, dated 06/08/22, revealed the facility would ask upon admission for any history of pneumococcal vaccinations and their age at the time of the vaccination. If their was no evidence, the vaccination would be offered at time of admission. For immune compromised residents age [AGE] or younger at the time of the vaccination and more than five years have passed, a booster would be offered. Candidates for the vaccine include age [AGE] or older, serious long term health conditions, resistance to infection lowered due to diagnoses and if Alaskan Native or certain American populations. The policy also states recommendations were available from the CDC on specific situations where vaccination was indicated outside the previously mentioned indications, as well as directions on additional boosters and may be recommended for certain at risk groups. Resident and representatives should be educated on the benefits and risk of pneumococcal vaccines and see the CDC guidelines (attached); (with no attachment provided). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 26 of 28 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 02/15/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccination/booster and provided education on vaccinations. This affected three (#8, #15, and #69) of five reviewed for vaccination. Additionally, the facility failed to have a policy and procedure related to residents receiving the COVID-19 Vaccination, which affected all facility residents. Findings census was 65. Findings include 1. Review of the medical record for Resident #8 revealed an admission date of 08/24/21. Diagnoses included stroke, hepatic failure, diabetes, schizophrenia, depressions and anemia. Review of the vaccination records revealed Resident #15 was given the COVID-19 vaccination (2 dose) dated 12/09/21 and 01/07/22. Chart review revealed no evidence of the COVID-19 vaccination booster was offered and no evidence education was provided in relation to risks and benefits of receiving the COVID vaccine booster. 2. Review of the medical record for Resident #15 revealed an admission date of 09/12/23. Diagnoses included dementia, obesity, stenosis of coronary artery, altered mental status and failure to thrive. Review of the vaccination records revealed Resident #15 was given the COVID-19 vaccination (2 dose) dated 05/28/21. Chart review revealed no evidence of the COVID-19 vaccination booster was offered since admission and no evidence of education was provided in relation to risks and benefits of receiving the COVID vaccine. 3. Review of the medical record for Resident #69 revealed an admission date of 01/16/24. Diagnoses included cellulitis of left lower limb, unspecified convulsions and need for assistance with personal care. Review of the vaccination records revealed no evidence of the COVID-19 vaccinations being offered, refused or accepted. Chart review also revealed no evidence that education was provided in relation to risks and benefits of receiving the COVID vaccine. Interview on 02/14/24 at 2:39 P.M., with Director of Nursing revealed dates should be documented and education boxes can be checked when staff enter the vaccination information. After review of several vaccines revealed some dates were not being shown to show evidence of vaccines being offered, declined, or accepted and also DON confirmed no evidence of education was completed. DON revealed facility documents immunizations under the immunizations tab and reported this information would not be in any other documentation source such as a progress note. Interview on 02/14/24 at 2:50 P.M., with Clinical Corporate Registered Nurse (RN) #263 confirmed facility did not have a way to show education had been provided related to vaccinations. Interview on 02/14/24 at 4:20 P.M., with Clinical Corporate RN #263 reported facility had no policy and procedure in relation to administering COVID-19 vaccinations to residents. She revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 27 of 28 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 02/15/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm facility uses the Quick guide and follows CDC guidelines. The quick guide had no information on resident vaccination but was a guide for staff on other aspects of COVID-19 including testing and what to do for positive or suspected positive cases. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365619 If continuation sheet Page 28 of 28