Inspection·February 6, 2020

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of STNA #325's statement revealed she claimed to be joking and kidding with Resident #21 about taking her to the strip clubs where they could smoke and drink. STNA #325 reported not being the only one who teases the resident and that most of the time the resident would laugh. STNA #325's statement further revealed kidding Resident #21 about a (descriptive) guy named Individual #19 that will get her and take her out when he gets out of prison and that she could have sex. STNA #325 reported telling the resident she could get all fixed up and look all hot and sexy, get drunk and have sex. STNA #325 reported asking Resident #21 if she would like her boyfriend to come and get her so she could be a bad girl and have dirty sex. STNA #325 reported at this time Resident #21 stated, no I don't like that. STNA #325's statement revealed stating that she was just kidding and that she was trying to get the resident to laugh and stop crying. Review of an untitled form dated 12/03/19 revealed STNA #325 was counseled on rude and discourteous behavior towards Resident #21. STNA #325 was documented as adamantly denying the accusation. The form was signed by Licensed Practical Nurse (LPN) #315 and Registered Nurse (RN) #320. Review of a form titled, Employee Termination Form dated 12/03/19 revealed STNA #325 was involuntarily terminated this date for substantiated abuse. Review of Resident #21's nursing progress notes dated 12/06/19 at 9:05 A.M. revealed a documented incident with STNA #325 being rude and verbalizing discourteous statements that were witnessed by another aide. The note indicated the incident was reported by a STNA on 12/03/19 and an investigation completed, SRI initiated and STNA #325 removed from the schedule. The note further indicated the resident's representative and physician being notified of the incident. The note documented the resident was assessed and interviewed without residual effects of the incident. Interview on 02/04/20 at 11:30 A.M. with the DON revealed that it was reported to her by STNA #260 through a telephone call towards the end of second shift on 11/29/19 that STNA #325 had been disrespectful to Resident #21. STNA #260 reported she felt uncomfortable due to the words that STNA #325 had used. The DON also reported that STNA #260 had reported the incident to RN #320 who was on duty and reprimanded STNA #325 this date. The DON reported STNA #325 had denied the accusations and that the incident originated with STNA #325 being reported as stating uncomfortable things to the resident. The DON reported that the situation elaborated on 12/03/19 when STNA #260 had reported more graphic detail of what STNA #325 had actually verbalized to Resident #21. On 12/03/19 after the receipt of the additional information, the facility initiated a SRI and suspended STNA #325. Interview on 02/04/20 at 2:50 P.M. with STNA #260 confirmed working with STNA #360 stating the incident occurred towards the end of their shift on 11/29/19. STNA #260 reported STNA #360 had told Resident #21 to be quiet and to shut up and that STNA #325 would have a (descriptive) guy from prison come in to have sex with her. STNA #260 confirmed she reported the incident to LPN #315 and then went into the employee breakroom and notified the DON. Interview on 02/04/20 at 3:09 P.M. with LPN #315 confirmed being on duty 11/29/19 at the time of the incident. LPN #315 reported STNA #325 had stated she was going to have a (descriptive) man hold Resident #21's head down and stick it to her until she yelled. LPN #315 reported that STNA #325 repeated this again and that she was just kidding. LPN #315 stated she could not recall what the exact details of what was said but advised STNA #325 that it was not acceptable. LPN #315 reported the conversation was witnessed by STNA #260 when in the room with STNA #325 providing care to Resident #21. LPN #315 confirmed she reported the incident to the DON but was so upset that she handed the telephone to RN #320 to provide the DON the details of the verbal abuse. LPN #315 stated she and RN #320 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 2 of 15 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 02/06/2020 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few spoke with STNA #325 again after speaking with the DON and that STNA #325 was voicing worries that she would get into trouble and that she would not do it again. Interview on 02/05/20 at 9:15 A.M. with the DON and the Administrator confirmed STNA #325's employment was terminated on 12/03/19 following the additional information the facility received regarding the incident. Review of a facility provided policy titled, Abuse Investigation and Reporting with a revision date of 12/2017 revealed all reports of resident abuse, neglect, exploitation, misappropriation or resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The individual conducting the investigation will at a minimum, a) review the completed documentation forms, b) review the resident's medical record to determine events leading up to the incident, c) interview the person(s) reporting the incident, d) interview any witnesses to the incident, e) interview the resident (as medically appropriate), f) interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition, g) interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, h) interview the resident's roommate, family members, and visitors, i) interview other residents to whom the accused employee provides care or services, j) review all events leading up to the alleged incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 3 of 15 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 02/06/2020 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of a self-reported incidents (SRI's) review of witness statements, review of personnel files, the facility failed to timely report an allegation of staff to resident verbal abuse to the state agency. This affected one (#21) of one resident reviewed for abuse. The facility census was 32. Findings include: Review of the medical record for Resident #21 revealed an admission date of 10/24/16. Diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain), anxiety disorder, chronic kidney disease, schizophrenia, major depressive disorder, allergic rhinitis, vitamin D deficiency, difficulty walking, unspecified dementia with behavioral disturbance, muscle weakness, schizoaffective disorder, mental disorders and disorders of intestinal carbohydrate absorption. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively impaired and required extensive assistance with bed mobility, transferring, eating, toileting and activities of daily living. Review of the facility SRI revealed the date of the occurrence documented as 11/29/19 at 10:30 P.M. Continued review of the SRI revealed the incident to be reported to the state agency on 12/03/19. Narrative summary of the incident revealed a written statement was obtained on 12/03/19 at approximately 11:00 A.M. from State Tested Nurse Aide (STNA) #260 witnessing STNA #325 being rude and disrespectful to Resident #21 when providing care. Further review of the facility report revealed STNA #260 reported the incident to Registered Nurse (RN) #320 who documented reprimanding STNA #325. The SRI indicated that on 12/03/19 additional details were reported to the Administrator at which time the SRI was initiated. Review of STNA #260's witness statement dated 12/03/19 revealed assisting STNA #325 with putting Resident #21 to bed who was screaming which was a frequent behavior. STNA #260 reported witnessing STNA #325 tell Resident #21 that she knew of a way to get her to shut up. STNA #325 was overheard telling Resident #21 that she would get (a descriptive) man from prison named Individual #19 would come perform a sex act on Resident #21. Continued review of STNA #260's statement revealed exiting the residents room and entering the nursing station where STNA #325 began telling Licensed Practical Nurse (LPN) #315 and Registered Nurse (RN) #320 what she had said. STNA #260 reported then notifying the Director of Nursing (DON) of the incident relaying that the DON would have RN #320 speak to STNA #325. Review of STNA #325's statement revealed she claimed to be joking and kidding with Resident #21 about taking her to the strip clubs where they could smoke and drink. STNA #325 reported not being the only one who teases the resident and that most of the time the resident would laugh. STNA #325's statement further revealed kidding Resident #21 about a (descriptive) guy named Individual #19 that will get her and take her out when he gets out of prison and that she could have sex. STNA #325 reported telling the resident she could get all fixed up and look all hot and sexy, get drunk and have sex. STNA #325 reported asking Resident #21 if she would like her boyfriend to come and get her so she could be a bad girl and have dirty sex. STNA #325 reported at this time Resident #21 stated, no I don't like that. STNA #325's statement revealed stating that she was just kidding and that she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 4 of 15 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 02/06/2020 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 0609 trying to get the resident to laugh and stop crying. Level of Harm - Minimal harm or potential for actual harm Review of an untitled form dated 12/03/19 revealed STNA #325 was counseled on rude and discourteous behavior towards Resident #21. STNA #325 was documented as adamantly denying the accusation. The form was signed by LPN #315 and RN #320. Residents Affected - Few Review of a form titled, Employee Termination Form dated 12/03/19 revealed STNA #325 was involuntarily terminated this date for substantiated abuse. Review of Resident #21's nursing progress notes dated 12/06/19 at 9:05 A.M. revealed a documented incident with STNA #325 being rude and verbalizing discourteous statements that were witnessed by another aide. The note indicated the incident was reported by a STNA on 12/03/19 and an investigation completed, SRI initiated and STNA #325 removed from the schedule. The note further indicated the resident's representative and physician being notified of the incident. The note documented the resident was assessed and interviewed without residual effects of the incident. Interview on 02/04/20 at 11:30 A.M. with the DON revealed that it was reported to her by STNA #260 through a telephone call towards the end of second shift on 11/29/19 that STNA #325 had been disrespectful to Resident #21. STNA #260 reported she felt uncomfortable due to the words that STNA #325 had used. The DON also reported that STNA #260 had reported the incident to RN #320 who was on duty and reprimanded STNA #325 this date. The DON reported STNA #325 had denied the accusations and that the incident originated with STNA #325 being reported as stating uncomfortable things to the resident. The DON reported that the situation elaborated on 12/03/19 when STNA #260 had reported more graphic detail of what STNA #325 had actually verbalized to Resident #21. On 12/03/19 after the receipt of the additional information, the facility initiated a SRI and suspended STNA #325. Interview on 02/04/20 at 2:50 P.M. with STNA #260 confirmed working with STNA #360 stating the incident occurred towards the end of their shift on 11/29/19. STNA #260 reported STNA #360 had told Resident #21 to be quiet and to shut up and that STNA #325 would have a (descriptive term) guy from prison come in to have sex with her. STNA #260 confirmed she reported the incident to LPN #315 and then went into the employee breakroom and notified the DON. Interview on 02/04/20 at 3:09 P.M. with LPN #315 confirmed being on duty 11/29/19 at the time of the incident. LPN #315 reported STNA #325 had stated she was going to have a (descriptive) man hold Resident #21's head down and stick it to her until she yelled. LPN #315 reported that STNA #325 repeated this again and that she was just kidding. LPN #315 stated she could not recall what the exact details of what was said but advised STNA #325 that it was not acceptable. LPN #315 reported the conversation was witnessed by STNA #260 when in the room with STNA #325 providing care to Resident #21. LPN #315 confirmed she reported the incident to the DON but was so upset that she handed the telephone to RN #320 to provide the DON the details of the verbal abuse. LPN #315 stated she and RN #320 spoke with STNA #325 again after speaking with the DON and that STNA #325 was voicing worries that she would get into trouble and that she would not do it again. Interview on 02/05/20 at 9:15 A.M. with the DON and the Administrator confirmed STNA #325's employment was terminated on 12/03/19 following the additional information the facility received regarding the incident. Review of a facility provided policy titled, Abuse Investigation and Reporting with a revision date of 12/2017 revealed all reports of resident abuse, neglect, exploitation, misappropriation or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 5 of 15 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 02/06/2020 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The individual conducting the investigation will at a minimum, a) review the completed documentation forms, b) review the resident's medical record to determine events leading up to the incident, c) interview the person(s) reporting the incident, d) interview any witnesses to the incident, e) interview the resident (as medically appropriate), f) interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition, g) interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, h) interview the resident's roommate, family members, and visitors, i) interview other residents to whom the accused employee provides care or services, j) review all events leading up to the alleged incident. Event ID: Facility ID: 365970 If continuation sheet Page 6 of 15 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 02/06/2020 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 0610 Respond appropriately to all alleged violations. 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 a self-reported incident (SRI), review of witness statements, review of personnel files, staff interviews, and policy review, the facility failed to conduct a thorough investigation following an allegation of verbal abuse and the facility failed to protect residents from potential further abuse when there was an abuse allegation. This affected one resident (#21) of one resident reviewed for abuse. This had the potential to affect 28 of 32 residents except for four (#3, #16, #19 and #34) residents who are independent. The facility census was 32. Residents Affected - Some Findings include: Review of the medical record for Resident #21 revealed an admission date of 10/24/16. Diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain), anxiety disorder, chronic kidney disease, schizophrenia, major depressive disorder, allergic rhinitis, vitamin D deficiency, difficulty walking, unspecified dementia with behavioral disturbance, muscle weakness, schizoaffective disorder, mental disorders and disorders of intestinal carbohydrate absorption. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively impaired and required extensive assistance with bed mobility, transferring, eating, toileting and activities of daily living. Review of the facility SRI revealed the date of the occurrence was documented as 11/29/19 at 10:30 P.M. Continued review of the SRI revealed the incident to be reported to the state agency on 12/03/19. Narrative summary of the incident revealed a written statement was obtained on 12/03/19 at approximately 11:00 A.M. from State Tested Nurse Aide (STNA) #260 witnessing STNA #325 being rude and disrespectful to Resident #21 when providing care. Further review of the facility report revealed STNA #260 reported the incident to Registered Nurse (RN) #320 who documented reprimanding STNA #325. The SRI indicated that on 12/03/19 additional details were reported to the Administrator at which time the FRI was initiated. Review of STNA #260's witness statement dated 12/03/19 revealed assisting STNA #325 with putting Resident #21 to bed who was screaming which was a frequent behavior. STNA #260 reported witnessing STNA #325 tell Resident #21 that she knew of a way to get her to shut up. STNA #325 was overheard telling Resident #21 that she would get (a descriptive) man from prison named Individual #19 would come perform a sex act on Resident #21. Continued review of STNA #260's statement revealed exiting the residents room and entering the nursing station where STNA #325 began telling Licensed Practical Nurse (LPN) #315 and Registered Nurse (RN) #320 what she had said. STNA #260 reported then notifying the Director of Nursing (DON) of the incident relaying that the DON would have RN #320 speak to STNA #325. Review of STNA #325's statement revealed she claimed to be joking and kidding with Resident #21 about taking her to the strip clubs where they could smoke and drink. STNA #325 reported not being the only one who teases the resident and that most of the time the resident would laugh. STNA #325's statement further revealed kidding Resident #21 about a (descriptive) guy named Individual #19 that will get her and take her out when he gets out of prison and that she could have sex. STNA #325 reported telling the resident she could get all fixed up and look all hot and sexy, get drunk and have sex. STNA #325 reported asking Resident #21 if she would like her boyfriend to come and get her so she could be a bad girl and have dirty sex. STNA #325 reported at this time Resident #21 stated, no I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 7 of 15 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 02/06/2020 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some don't like that. STNA #325's statement revealed stating that she was just kidding and that she was trying to get the resident to laugh and stop crying. Continued review of the facility investigation revealed there was no documentation and/or information regarding any additional staff or resident interviews and/or statements being completed surrounding the incident. Interview on 02/05/20 at 9:15 A.M. with the Administrator and the DON confirmed the facility did not complete any additional staff or resident interviews regarding the incident and the only statements obtained were from the witness and the perpetrator. The DON confirmed STNA #325 was not removed from the schedule until 12/03/19 when STNA #260 reported the addition of more graphic information to the Administrator. The DON and Administrator confirmed STNA #325 was immediately suspended on 12/03/19 and subsequently terminated from employment the same date. The facility confirmed allowing STNA #325 to continue to work had the potential to affect 28 of 32 residents except for four (#3, #16, #19 and #34) residents who are independent and who the aide had access to. Review of an untitled form dated 12/03/19 revealed STNA #325 was counseled on rude and discourteous behavior towards Resident #21. STNA #325 was documented as adamantly denying the accusation. The form was signed by LPN #315 and RN #320. Review of a form titled, Employee Termination Form dated 12/03/19 revealed STNA #325 was involuntarily terminated this date for substantiated abuse. Review of a facility provided policy titled, Abuse Investigation and Reporting with a revision date of 12/2017 revealed all reports of resident abuse, neglect, exploitation, misappropriation or resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The individual conducting the investigation will at a minimum, a) review the completed documentation forms, b) review the resident's medical record to determine events leading up to the incident, c) interview the person(s) reporting the incident, d) interview any witnesses to the incident, e) interview the resident (as medically appropriate), f) interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition, g) interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, h) interview the resident's roommate, family members, and visitors, i) interview other residents to whom the accused employee provides care or services, j) review all events leading up to the alleged incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 8 of 15 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 02/06/2020 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 medical record review, observation and staff interview, the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected two (#31 and #2) of nine resident reviewed for accuracy of the assessment. The census was 32. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, hyperlipidemia, bradycardia, anxiety, hypothyroidism, major depressive disorder, congestive heart failure, neuromuscular dysfunction of the bladder, and anemia. Review of the medical record for Resident #31 revealed on 12/02/2019 the resident weight was 176 pounds. Further review of the resident weight documentation revealed on 01/14/20 the resident weight was 164.8 pounds. Review of Resident #31's weights revealed the resident had a significant weight loss of 6.3 percent in one month. Review of the medication administration record dated 01/20 revealed Resident #31 was administered the medication eliquis (anticoagulant), lasix (diuretic), mirtazapine (antidepressant), and ativan (antianxiety) on 01/14/20, 01/15/20, 01/16/20, 01/17/20, 01/18/20, and 01/20/20. Resident #31's medications (eliquis, lasix, mirtazapine and ativan) were not signed off as administered on 01/19/20. Review of an annual MDS assessment dated [DATE], revealed Resident #31 was not assessed to have a weight loss of five percent or more in the last month. Continued review of the MDS assessment revealed the resident was assessed to have been administered anticoagulant, diuretic, antidepressant, and antianxiety medication on seven days during the seven day reference period. Interview on 02/05/20 at 11:31 A.M. with Employee #400 verified Resident #31 had a 6.3 percent weight loss from 12/02/19 to 01/14/20. Continued interview with Employee #400 verified the annual MDS assessment dated [DATE] was not accurate and the assessment should have identified the resident to have had a weight loss of five percent or more in the last month. Interview on 02/05/20 at 2:24 P.M. with the Director of Nursing (DON) verified Resident #31 was administered anticoagulant, diuretic, antidepressant, and antianxiety medication on six days during the seven day reference period for the annual MDS dated [DATE]. The DON confirmed Residents #31's medications were not signed off as being administered on 01/19/20. The DON further verified the annual MDS assessment dated [DATE] was not accurate. 2. Review of Resident #2's medical record revealed an admission date of 09/21/14 with diagnosis of Parkinson's disease, atherosclerotic heart disease, dysphagia, mixed receptive expressive aphasia, unspecified abdominal pain, anxiety disorder, calculus of gallbladder with cholecystitis, benign prostatic hyperplasia, dementia with behavioral disturbance, constipation, major depression, muscle weakness and difficulty walking. Review of the Minimum Data Set (MDS) section M dated 10/29/19 revealed Resident #2 was identified as having an unhealed stage one pressure ulcer. Review of Resident #2's medical record no documentation of the resident having had any pressure ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 9 of 15 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 02/06/2020 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/04/20 at 10:35 A.M. with Licensed Practical nurse (LPN) #310 confirmed the resident's medical record had no documentation regarding a pressure ulcer and had no knowledge of Resident #2 having had a pressure ulcer. Observation on 02/04/20 at 12:20 P.M. of Resident #2's buttocks and sacral areas with LPN #310 revealed no pressure ulcers. Interview with the Director of Nursing (DON) on 02/04/20 at 5:00 P.M. confirmed the medical record had no documentation of a pressure ulcer and had no knowledge of Resident #32 having had a pressure ulcer. The DON confirmed the MDS had been coded incorrectly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 10 of 15 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 02/06/2020 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 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 resident record review, resident and staff interview, and policy review, the facility failed to ensure a resident and other required members of the interdisciplinary team were included in the care planning process. Additionally, the facility failed to complete care conference quarterly. This affected three (#22, #31, and #34) of three residents reviewed for care planning. The census was 32. Findings include: 1. Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses include neuromuscular dysfunction of the bladder, congestive heart failure, protein calorie malnutrition, anemia, chronic kidney disease, hypothyroidism, osteoarthritis, glaucoma, and kidney failure. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #22 had moderately impaired cognition. Quarterly MDS assessments were also completed on 12/12/19 and 01/06/20. Review of the medical record for Resident #22 revealed a care planning conference was held on 11/25/19. Documentation revealed no evidence of the resident or a state tested nurse aid (STNA) participating in the care planning process. Additionally, there was no evidence of the resident refusing to participate in the care planning process. Continued review of the medical record from 12/19 to 02/05/20 revealed no evidence of a care conference or of the resident being invited to participate in the care planning process for the assessments dated 12/12/19 and 01/06/20. Interview on 01/03/20 at 11:16 A.M. with Resident #22 revealed the resident had not been invited to participate in the care planning process. Interview on 02/03/20 at 4:24 P.M. with social service (SS) #305 revealed care conference are to be held whenever an MDS assessment was completed. SS #305 revealed a care conference sheet is kept for all care conference and whomever attends the conference signs in on the document. Interview with SS #305 verified Resident #22 was not invited to participate in the care conference because the resident representative was invited. SS #305 further verified there was no care conference held for the assessments completed 12/12/19 and 01/06/20. 2. Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, hyperlipidemia, bradycardia, anxiety, hypothyroidism, major depressive disorder, congestive heart failure, neuromuscular dysfunction of the bladder, and anemia. Review of an annual MDS assessment dated [DATE], revealed the resident had moderately impaired cognition. Review of Resident #31's medical record revealed no evidence of a care conference or of the resident being included in the care planning process for the annual comprehensive assessment dated [DATE]. Interview on 02/03/20 at 10:42 A.M. with Resident #31 revealed the resident was unsure if the facility had care conferences. The resident did not recall being invited to participate in the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 11 of 15 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 02/06/2020 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 0657 planning process. Level of Harm - Minimal harm or potential for actual harm Interview on 02/06/20 at 9:28 A.M. with SSD #305 verified there was no care conference held and the medical record contained no evidence of Resident #31 being included in the care planning process for the comprehensive assessment that was dated 01/20/29. Residents Affected - Few 3. Review of Resident #34's medical record revealed an admission date of 05/30/17 with diagnoses of hypertension, orthostatic hypotension, unspecified dementia without behaviors, schizophrenia, high risk heterosexual behavior. anxiety disorder, vitamin D deficiency, seborrheic keratosis, hypercholesterolemia and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition. Review of Resident #34's medical record revealed there had not been a quarterly care conference documented for May 2019. In addition, the care conference documentation dated 08/02/19 revealed a telephone conference had been conducted with a resident representative and only contained the documented signature of the Director of Nursing (DON) in attendance. Interview with Social Services Staff (SSS) #305 on 02/04/20 at 10:27 A.M. revealed care conferences were to be completed quarterly following the MDS assessments. Interview on 02/05/20 at 8:52 A.M. with SSS #305 confirmed the record had no evidence for Resident #34 having had a quarterly care conference in May 2019. Interview on 02/06/20 at 9:12 A.M. with Resident #34 revealed he had not been invited to his knowledge to attend any care conferences. Review of a facility policy titled, Resident Participation-Assessment/Care Plans with a revision date of 02/2018 revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail, email and/or telephone. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. The notices include a) the date, time and location of the conference; b) the name of each person contacted and the date he or she was contacted; c) the method of contact; d) input from the resident or representative if they are not able to attend; e) refusal of participation; and f) the date and signature of the individual making the request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 12 of 15 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 02/06/2020 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview; the facility failed to administered medication as ordered by the physician. This affected one (#31) of five resident reviewed for unnecessary medication. The census was 32. Findings include: Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, hyperlipidemia, bradycardia, anxiety, hypothyroidism, major depressive disorder, congestive heart failure, neuromuscular dysfunction of the bladder, and anemia. Review of the medication administration record (MAR) dated 01/20, revealed Resident #31 was to be administered the medication Carvedilol tablet 3.125 milligram (mg) one tablet by mouth every day and every evening shift to prevent cardiovascular event related to atherosclerotic heart disease. The instructions included parameters to hold the medication if systolic blood pressure (SBP) was less than 90 or pulse was less than 50. Continued review of the MAR revealed on 01/07/20 (day) the resident was administered Carvedilol when the resident pulse was 48. Continued review of the MAR revealed on eight days the medication was was not administered to Resident #31 when the residents blood pressure and pulse did not fall below the parameters. Review of the MAR revealed on 01/10/20 (evening) Resident #31's blood pressure (BP) was 108/52 milligrams of mercury (mmHg), pulse was 55; on 01/11/20 (evening) BP 111/62 mmHg, pulse 58, on 01/12/20 (day) BP 109/57 mmHg, pulse 54; on 01/15/20 (evening) no documented BP, pulse 52; on 01/17/20 (evening) no documented BP, pulse 52, on 01/21/20 (evening) no documented BP, pulse 51; on 01/26/20 (evening) no documented BP, pulse 51; on 01/28/20 (evening) BP 106/55 mmHg, pulse 63. Further review of the blood pressure and pulse documentation for Resident #31, documented in the vital signs area of the electronic health record, revealed the same information as noted on the MAR. Interview on 02/05/20 at 2:24 P.M. with the Director of Nursing (DON) verified Resident #31 was not administered Carvedilol as ordered by the physician during the month of 01/20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 13 of 15 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 02/06/2020 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of a facility policy, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 31 residents the facility identified as eating from the facility kitchen. (Resident #18 did not eat from the facility kitchen). The facility census was 32. Findings include: During the initial kitchen tour on 02/03/20 at 9:00 A.M. observation revealed a long handled ladle to be present in the plastic storage bin laying atop the sugar. Interview with Dietary Manager #300 on 02/03/20 at 9:00 A.M. at the time of the discovery confirmed the long handled ladle to be present and laying atop the sugar in the dry storage bin. The facility confirmed this had the potential to affect 31 residents who receive meals from the facility kitchen. (Resident #18 did not eat from the facility kitchen). Review of a facility provided policy titled, Food Receiving and Storage with a revision date of 02/2018 revealed dry foods shall be stored in bins and no utensils will be left in containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 14 of 15 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 02/06/2020 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of a facility policy, review of a facility document, review of a Survey and Certification (S&C) memo and staff interview, the facility failed to develop and implement specific testing protocols through their Legionella Water Management Program. This had the potential to affect all 32 residents residing in the facility. The facility census was 32. Residents Affected - Many Findings include: Review of the facility policy titled Legionella Water Management Program dated 12/17 revealed there were no specific testing protocols identified. Review of the program documentation, completed by the facility, revealed there was no documentation regarding specific testing protocols being completed to prevent Legionella. Review of S&C Memo 17-30 titled Hospitals/Critical Access Hospitals (CAHs)/Nursing Homes (NHs) revealed facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1. Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; 2. Develops and implements a water management program that considers the ASHRAE industry standard and the Centers for Disease Control and Prevention (CDC) toolkit; and 3. Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Testing protocols are at the discretion of the provider. Interview on 02/06/20 at 10:55 A.M. with the Director of Nursing (DON) verified the facility did not develop and/or implement any specific testing protocols (i.e. hot water flushing, chlorine testing, etc.) to prevent Legionella. The DON confirmed this had the potential to affect all 32 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365970 If continuation sheet Page 15 of 15