Inspection·January 10, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to ensure advanced directives listed in two areas of the resident medical record, were consistent. This affected three (#16, #18, and #35) of 16 resident records reviewed for advanced directive. The census was 40. Findings include: 1. Review of the medical record for Resident #16 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic respiratory failure, heart failure, hypothyroidism, anxiety disorder, chronic obstructive pulmonary disease, neuromuscular dysfunction of the bladder, diabetes mellitus type two, hyperlipidemia, schizophrenia, hypertension, peripheral venous insufficiency, and asthma. Review of the Do Not Resuscitate (DNR) identification form dated 03/19/18, revealed Resident #16's code status was DNR comfort care (CC) arrest (A). Continued review of the medical record revealed a physician order sheet dated 01/19, which identified Resident #16 was a full code. Review of the medical record for Resident #16 revealed the medical record contained conflicting information related to the residents code status. Interview on 01/07/18 at 4:00 P.M. with licensed practical nurse (LPN) #250 revealed the advanced directive were located in a resident medical record. LPN #250 revealed a residents code status is located under the advanced directives tab and on the physician orders sheet. LPN #250 verified Resident #16's DNR identification form documented the resident was a DNRCC-A. The LPN further verified Resident #16's physician order sheet documented the resident was a full code. LPN #250 confirmed the medical record for Resident #16 contained conflicting documentation related to the residents advanced directives. The LPN reported the conflicting information would need to be clarified by the director of nursing. 2. Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, major depressive disorder, anemia, hypokalemia, hypertension, and lymphedema. Review of the DNR identification form dated 10/30/18 revealed Resident #18's status was DNRCC-A. Review of a physician order dated 10/30/18 revealed an order to discontinue full code status per the resident request for DNRCC-A. Review of the physician order sheet dated 01/19 identified the resident code status was full code. Interview on 01/07/18 at 4:05 P.M. with LPN #250 verified Resident #18's DNR identification form documented the resident's code status was DNRCC-A. The LPN further verified Resident #18's physician order sheet documented Resident #18 was a full code. LPN #250 confirmed the medical record for Resident #18 contained conflicting documentation related to the residents code status. 3. Review of the medical record for Resident #35 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebrovascular disease, malignant neoplasm of the face, benign neoplasm of cerebral meninges, diabetes mellitus type two, hyperlipidemia, major depressive disorder, epilepsy, and hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 2 of 7 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 365970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Union City Care Center 907 East Central Street Union City, OH 45390 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the documented titled, Full Code dated 07/17/14 revealed the residents code status was full code. Review of the physician order dated 01/19, revealed the resident code status was DNRCC-A. Review of the medical record for Resident #35 revealed the medical record contained conflicting documentation related to the residents code status. Interview on 01/07/19 at 4:10 P.M. with LPN #250 verified the documentation located under the advanced directive tab Resident #35's medical record was full code. The LPN further verified Resident #16's physician order sheet dated 01/19 identified the resident's code status was DNRCC-A. LPN #250 confirmed the medical record for Resident #16 contained conflicting documentation related to the residents advanced directives. Event ID: Facility ID: 365970 If continuation sheet Page 3 of 7 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 365970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Union City Care Center 907 East Central Street Union City, OH 45390 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to transmit minimum data set (MDS)assessments within 14 days after completion. This affected two (#1 and #2) of two resident records reviewed for MDS record over 120 days old. The census was 40. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include pyridoxine deficiency, hyperlipidemia, major depressive disorder, and hypertension. Review of Resident #2's quarterly MDS assessment target date 12/21/17, revealed the assessment was completed on 12/21/17. Continued review of the quarterly MDS assessment revealed the MDS was locked/submitted on 01/09/18. Interview on 01/09/19 at 5:01 P.M. with the Director of Nursing (DON) verified the quarterly assessment dated [DATE] for Resident #2 was not transmitted within 14 days after being completed. 2. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hypertension, obsessive compulsive disorder, schizophrenia, psychosis, bipolar disorder, anxiety, paraphilia, and Parkinson's disease. Review of Resident #1's annual MDS assessment target date 02/16/18, revealed the assessment was completed on 02/17/18. Continued review of the annual MDS assessment revealed the MDS was locked/submitted on 03/06/18. Interview on 01/09/19 at 5 :03 P.M. the DON verified the annual assessment dated [DATE] for Resident #1 was not transmitted within 14 days after being completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 4 of 7 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 365970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Union City Care Center 907 East Central Street Union City, OH 45390 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 record review and staff interview; the facility failed to ensure the minimum data set (MDS) assessments were accurate. This affected two (#38 and #20) of 12 residents reviewed for accuracy of the MDS assessment. The facility census was 40. Residents Affected - Few Findings include: 1. Review of the record for Resident #38 revealed the resident was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, hyperlipidemia, neuromuscular dysfunction of the bladder, anxiety, chronic pulmonary edema, anemia, diabetes mellitus Type Two, major depressive disorder, hypertension, chronic atrial fibrillation, and chronic kidney disease Stage Four. Further review of the record for Resident #38, revealed the resident was admitted to Hospice on 11/17/17. Admitting diagnoses was end stage congestive heart failure and chronic obstructive pulmonary disease. Review of a hospice comprehensive assessment and plan of care update report meeting dated 11/20/18, revealed Resident #38 was considered terminally ill with a life expectancy of six months or less based on current clinically relevant information, if the terminal illness runs its normal coarse. Review of the annual MDS assessment dated [DATE], revealed there was no assessment of Resident #38's condition/chronic disease that may result in a life expectancy of less than six months identified. Interview on 01/09/19 at 3:15 P.M. with the Director of Nursing (DON), verified Resident #38's annual MDS assessment dated [DATE] was not accurate and should have documented this information. 2. Review of the record for Resident #20 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbances, hypothyroidism, hyperlipidemia, major depressive disorder, hypertension, rhabdomyolysis, and syncope. Review of a medication administration record dated 10/18, revealed Resident #20 was administered the antibiotic medication Keflex from 10/17/18 to 10/24/18. Review of Resident #20's significant change MDS assessment dated [DATE], revealed the resident received antibiotic medication on five days during the seven day reference period. Interview on 01/09/18 at 3:19 P.M. with the DON verified the significant change MDS dated [DATE] for Resident #20 was not accurate. The DON confirmed Resident #20 was administered antibiotic medication on four days during the seven day reference period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 5 of 7 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 365970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Union City Care Center 907 East Central Street Union City, OH 45390 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to develop a baseline care plan. This affected one (#30) of six resident reviewed for the development of baseline care plans. The facility census was 40. Findings include: Review of the record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus Type Two, major depressive disorder, Alzheimer's disease, vascular dementia, calcium deficiency, hyperlipidemia, dementia with behavioral disturbances, psychosis, hearing loss, hypertension, psoriatic arthritis, gout, spinal stenosis, and chronic kidney disease. Further review of the record for Resident #30, revealed there was no 48 baseline care plan. Additionally, there was no documentation the 48 hour baseline care plan was given to the resident/resident representative. Interview on 01/08/19 at 2:06 P.M. with the Director of Nursing, verified the facility did not develop a 48 hour baseline care plan for Resident #30. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 6 of 7 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 365970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Union City Care Center 907 East Central Street Union City, OH 45390 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medication storage observation, staff interview and review of facility policy, the facility failed to properly label and store medications. This affected two of 40 residents reviewed for medication storage. The facility census was 40. Findings include: Observations on 01/09/19 at 9:39 A.M. of the 100 hallway medication cart, revealed an opened and undated metered dose inhaler containing the medication Ventolin. The Ventolin was prescribed to Resident #8. Review of the Ventolin packaging information revealed the medication should be discard 13 months after opening the foil package. Continued observation of the 100 hallway medication cart, revealed a vial of the inhalant medication Ipratropium/Albuterol solution prescribed to Resident #189. The Ipratropium/Albuterol was no longer being stored in the foil packet and was undated. Observations on 01/09/18 at 10:00 A.M. of the refrigerator located in the medication storage room, revealed an opened and undated multi-dose vial of the medication Influenza vaccine and an opened and undated multi-dose vial of Tuberculin solution. Interview on 01/09/19 at 9:41 A.M. with Licensed Practical Nurse (LPN) #200, verified the Ventolin inhaler prescribed to Resident #8 was opened and undated. LPN #200 further verified the vial of Ipratropium/Albuterol solution prescribed to Resident #189, was removed from foil pouch and not dated. LPN #200 revealed per the facilities pharmacy recommendations, Ventolin should be discarded 12 months after the pouch was opened and Ipratropium/Albuterol should be discarded seven days after being removed from the foil package. Interview on 01/09/19 at 10:02 A.M. with LPN #300, verified the vial of Influenza vaccine and vial of Tuberculin solution located in the medication storage room refrigerator was opened an undated. The LPN revealed per the facilities pharmacy recommendations, the Influenza vaccination should be discarded 28 days after opening and the Tuberculin solution should be discarded 30 days after opening. Review of a policy titled, Storage of Medication, revised 12/17, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility hall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 7 of 7