Inspection·October 31, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21. Resident #28 had a diagnosis of dementia. Residents Affected - Few Review of the MDS 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff for bed mobility and transfers and supervision with eating. The MDS reflected the resident had no weight loss and no pressure ulcers. Record review revealed a physician's order was noted, dated 09/24/22 for skin prep (forms a protective film to help reduce friction to the area) to heels at bedtime. Review of a skin sweep assessment revealed on 09/28/22 Resident #28 was had a blister on the right heel measuring 4.2 centimeters (cm) in length by 4.0 cm width. The area was noted to be unstageable (depth unable to be determined). There was no further description of the area. On 10/19/22 at 2:05 P.M. Resident #28 was observed to have a three cm long by 2.5 cm wide red/purple area on the right heel. The skin was intact. In addition, review of weight records revealed Resident #28 weighed 151 pounds on 09/10/22 and 142.2 pounds on 10/02/22. This represented an 8.8 pound, 5.8% significant weight loss in one month. Review of the facility provided matrix (required for the annual recertification survey by the State agency) noted Resident #28 had an unstageable pressure ulcer and weight loss. Record review revealed no documented evidence Resident #28's responsible party was notified of the significant weight loss. There was no evidence the responsible party was notified of the pressure ulcer on the heel until 10/12/22 at a care plan conference (2 weeks after the area was identified). In addition, record review revealed no evidence the physician was notified of the development of the pressure ulcer or significant weight loss. On 10/20/22 at 3:35 P.M. and 3:50 P.M. interview with Registered Nurse (RN) #502 confirmed there was no documented evidence Resident #28's responsible party was notified timely of the development of the pressure ulcer to the resident's heel or evidence the responsible party was notified of the significant weight loss. In addition, RN #502 verified there was no evidence the physician was notified of the pressure ulcer to the heel or the significant weight loss. Review of the facility undated policy titled Notification of Changes Policy revealed it was the policy of the facility that changes in a residents condition or treatment were immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The policy noted requirements for notification of resident, the resident representative, and their physician included a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly (discontinue an existing form of treatment or commence a new form of treatment). Review of the facility undated Weight Loss Protocol revealed to notify the physician of any significant weight change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 2 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0580 Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and facility policy review the facility failed to ensure timely notification to the physician and resident representative related to the development of new pressure ulcer areas and/or significant weight loss. This affected two residents (#22 and #28) of two residents reviewed for notification. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date on 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the care plan, dated 07/08/17 revealed Resident #22 had actual and potential for impaired skin integrity. Interventions included report any red or open areas as indicated. The resident also had a plan related to risk for altered nutrition and hydration. Interventions included notify the registered dietitian (RD) and physician (MD) of significant weight changes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total dependence from one to two staff for all activities of daily living (ADLs), except eating. The resident required supervision with set up help only with eating. The resident's weight was 159 pounds with no noted weight loss. No pressure ulcer areas were noted on the assessment. Review of weights dated from 07/01/22 to current (10/20/22) revealed Resident #22 weighed 165 pounds (lbs) on 07/10/22 and 155 lbs on 07/17/22, a weight loss of five percent (5%). Resident #22 weighed 156 lbs on 10/05/22 and 146 lbs on 10/20/22, a weight loss of five percent since 09/18/22, 7.5% since 07/24/22, and 10% since 04/28/22. Review of skin sweep assessments revealed Resident #22 developed a Stage III pressure ulcer to the coccyx on 09/28/22. Review of progress notes, from 07/01/22 to 10/20/22 revealed there was no documented evidence the physician or resident representative were notified of Resident #22's weight changes (loss) or the development of the new pressure ulcer area. Review of the current physician's orders for October 2022 revealed Resident #22 had the following orders in place: Remeron (anti-depressant) 7.5 milligrams (mg) one tablet daily for weight loss, Arginaid Extra Liquid (nutritional supplement) 240 milliliters (mL) daily to promote weight gain, Boost VHC Liquid (nutritional supplement) 120 mL twice daily, and skin assessment weekly (on day shift every Friday). Interview on 10/20/22 at 3:45 P.M. with Registered Nurse (RN) #502 confirmed neither the physician nor the resident's representative were notified of the new pressure ulcer identified on 09/28/22. Interview on 10/24/22 at 6:10 P.M. with the Director of Nursing (DON) confirmed there was no indication Resident #22's representative or physician were notified of the resident's changes in weight. Review of the undated facility policy titled Notification Of Changes Policy revealed requirements (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 3 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0580 for notification of the resident, the resident representative and their physician included a significant change in the resident's physical, mental, or psychosocial status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 4 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy review and interview the facility failed to provide an Advanced Beneficiary Notice (ABN) as required to Resident #12 and Resident #28 who were cut from Medicare Part A therapy services and remained in the facility. This affected two residents (#12 and #28) of three residents reviewed for beneficiary notices. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 04/01/22 with medical diagnoses including unspecified dementia, generalized anxiety disorder, paranoid schizophrenia, adjustment disorder with depressed mood, chronic myeloproliferative disease, and delirium due to a known physiological condition. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22 revealed Resident #12 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. The assessment revealed Resident #12 required limited to extensive assistance from one staff to complete activities of daily living (ADLs). Review of the beneficiary notices for Resident #12 revealed the resident was discontinued (cut) from therapy on 05/30/22 and remained in the facility. Record review revealed Resident #12 was not provided with an Advanced Beneficiary Notice (ABN) prior to therapy services being discontinued as required. Interview on 10/20/22 at 8:45 A.M. with Social Services (SS) #572 confirmed Resident #12 was not provided with an ABN. SS #572 indicated she did not know the notice was required. 2. Review of the medical record for Resident #28 revealed an admission date on 07/01/21 with medical diagnoses including COVID-19, rhabdomyolosis, osteoarthritis, unspecified dementia, scoliosis, and repeated falls. Review of the Medicare five day MDS 3.0 assessment, dated 08/11/22 revealed Resident #28 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of four out of 15. The assessment revealed Resident #28 required extensive assistance from one to two staff to complete ADL care. Review of the beneficiary notices for Resident #28 revealed the resident was discontinued (cut) from therapy on 08/10/22 and remained in the facility. Record review revealed Resident #28 was not provided with an Advanced Beneficiary Notice (ABN) prior to therapy services being discontinued as required. Interview on 10/20/22 at 8:45 A.M. with Social Services (SS) #572 confirmed Resident #12 was not provided with an ABN. SS #572 indicated she did not know the notice was required. A facility policy was requested during an interview with the Director of Nursing (DON). However, the facility did not have a policy related to ABN notices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 5 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the State Long Term Care Ombudsman office was notified of facility initiated emergency transfers. This affected two residents (#44 and #45) of two residents reviewed requiring emergency transfers in the past three months. Findings include: Review of the medical record for Resident #44 revealed an admission date of 09/08/22. Record review revealed the resident was transferred to the hospital on [DATE]. Review of the medical record for Resident #45 revealed an admission date of 01/24/18. Record review revealed the resident was transferred to the hospital on [DATE]. Record review revealed no evidence the State Long Term Care Ombudsman office had been notified of the facility initiated emergent transfers to the hospital as required (at least 30 days had passed since the transfers occurred). Interview with Social Service (SS) #572 on 10/25/22 at 11:18 A.M. revealed the State Long Term Care Ombudsman office had not been notified of any facility initiated emergent transfers in the past year. SS #572 confirmed the Ombudsman were to be notified of the transfers at least every 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 6 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on record review and staff interview the facility failed to complete a comprehensive (Minimum Data Set (MDS) 3.0) assessment within 14 days after admission. This affected one resident (#30) of 14 residents reviewed for comprehensive MDS 3.0 assessments. Findings include: Review of the medical record for Resident #30 revealed an admission date of 09/27/22. The resident had diagnoses including end stage renal disease with hemodialysis, chronic pain, and rheumatoid arthritis. The resident had a physician's order for hemodialysis three times weekly and was on a renal diet. Record review revealed there was no evidence a comprehensive Minimum Data Set (MDS) 3.0 assessment had been completed for Resident #30 since admission. Interview with the Administrator on 10/25/22 at 9:25 A.M. confirmed the MDS 3.0 assessment had not been completed for the resident. The Administrator revealed the Director of Nursing, Assistant Director of Nursing, and the MDS nurse had all quit working at the facility around mid September 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 7 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, facility policy review and interview the facility failed to ensure comprehensive care plans were developed and initiated for each resident. This affected three residents (#30, #39 and #43) of 14 residents reviewed for comprehensive care plans. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 09/27/22. The resident had diagnoses including end stage renal disease with hemodialysis, chronic pain, and rheumatoid arthritis. The resident had a physician's order for hemodialysis three times weekly and was on a renal diet. Record review revealed no evidence a comprehensive plan of care had been developed and initiated for Resident #30 since admission. Interview with the Administrator on 10/25/22 at 9:25 A.M. confirmed a comprehensive care plan had not been developed/completed for the resident. The Administrator revealed the Director of Nursing, Assistant Director of Nursing, and the Assessment (MDS) nurse had all quit working at the facility around mid September 2022. 2. Review of the medical record for Resident #43 revealed an admission date of 09/21/22. The resident had diagnoses including postherpetic trigeminal neuralgia, hypertension, lymphedema, acute kidney failure, and abdominal aneurysm. Record review revealed a comprehensive assessment was completed on 09/28/22. However, review of the corresponding plan of care for the resident revealed it only addressed range of motion and transfers. Interview with Licensed Practical Nurse #516 on 10/25/22 at 11:15 A.M. confirmed a comprehensive care plan had not yet been developed and should have been. She confirmed areas identified on the assessment with the need for care planning included bladder incontinence, fall risk, nutrition, high risk for skin breakdown, pain, side rails, and activities of daily living. 3. Review of the medical record for Resident #39 revealed an admission date on 09/06/22 with diagnoses including unspecified dementia without behavioral disturbance and unspecified psychosis not due to a substance or known physiological condition. Review of the Medicare five day Minimum Data Set (MDS) 3.0 assessment, dated 09/13/22 revealed Resident #39 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #39 required limited assistance from one to two staff to complete bed mobility, transfers, ambulation/mobility, and dressing tasks. The resident required extensive assistance from one staff to complete hygiene and toileting tasks. The assessment revealed Resident #39 was administered daily antipsychotic and antidepressant medications. Review of the plan of care, dated 09/14/22 revealed neither Resident #39's diagnosis of dementia or use of psychoactive medications were addressed in the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 8 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of the current physician orders, dated October 2022 revealed Resident #39 had the following orders: palliative care with contracted Hospice, monitor behaviors (refusing medications, resisting care for hygiene, agitation, and tearful/withdrawn), Seroquel (an antipsychotic medication) 25 milligrams (mg) daily related to psychotic disorder, and Sertraline Hydrochloride (an antidepressant medication) 25 mg daily for depression. Residents Affected - Few Interview on 10/25/22 at 9:25 A.M. with the Administrator confirmed Resident #39's care plan did not address dementia or use of psychoactive medications. The Administrator indicated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and MDS nurse had all quit/left the facility around 09/10/22 and the facility was currently recruiting for those positions at the time of the survey. Review of the facility policy titled Care Plan, dated 02/11/08 revealed acute care plans would be initiated upon admission if there were high risk areas for admitting residents. High risk areas were defined as falls, elopement risks, skin, nutrition/hydration, and behaviors. When care plans were not needed for high risk areas, each discipline on the interdisciplinary team had until twenty days after admission to complete a care plan and have it on the resident's medical chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 9 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21 and a diagnosis of dementia. Residents Affected - Few Review of the MDS 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff for bed mobility and transfers and had no pressure ulcers. The plan of care dated 08/03/21 revealed the resident had a potential for impaired skin integrity related to decreased mobility and diagnosis/disease processes. Review of facility skin sweeps, dated 09/06/22, 09/13/22, 09/20/22, and 09/27/22 revealed the resident had no pressure areas and bony prominences were without issues. Skin remained intact at present time. No skin breakdown any of type was identified. Record review revealed a physician's order was obtained on 09/24/22 for skin prep (forms a protective film to help reduce friction to the area) to heels at bedtime. There was no reason documented for the order. Review of a skin sweep assessment, dated 09/28/22 revealed the resident had a blister on the right heel measuring 4.2 centimeters (cm) by 4.0 cm. The area was noted to be unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage III or Stage IV pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur). Record review revealed there was no further description of the area. The assessment noted skin prep was ordered and applied per order. Observations on 10/19/22 at 2:05 P.M. revealed Resident #28 had a three centimeter (cm) long by 2.5 cm wide red/purple area on the right heel. The skin was intact. Interview with Licensed Practical Nurse #518 at the time of the observation verified the presence of the area. Review of the plan of care revealed no evidence it was reviewed and revised after the development of the pressure ulcer to the right heel. Interview with Registered Nurse #502 on 10/20/22 at 3:35 P.M. confirmed Resident #28's plan of care had not been reviewed and revised after the development of the pressure ulcer on the right heel on 09/24/22. Based on observation, record review, facility policy review and interview the facility failed to ensure comprehensive care plans were revised following a change in condition for Resident #28 and Resident #32. This affected two residents (#28 and #32) of 14 residents reviewed for comprehensive care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 10 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 plans. Level of Harm - Minimal harm or potential for actual harm Findings Include: Residents Affected - Few 1. Review of the medical record for Resident #32 revealed an admission date on 08/13/21 with diagnoses including Alzheimer's Disease, unspecified displaced fracture of first cervical vertebra, pain, and other abnormalities of gait and mobility. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 08/22/22 revealed Resident #32 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #32 required staff supervision with set up assistance only to complete activities of daily living (ADLs). Review of progress note, dated 10/01/22 at 3:20 A.M. revealed a nurse sitting at the nurse's station heard a loud thud. Resident #32 attempted to go to the bathroom, fell, and hit her head. Resident #32 was conscious when she was sent to a local hospital for evaluation. On 10/02/22 at 1:30 A.M., the hospital nurse called to report Resident #32 had a C1 fracture and was to wear a neck brace at all times. Review of the current physician orders, dated October 2022 revealed Resident #32 had an order to check placement of C collar to neck every shift, check function and placement of alarms every shift, mat to floor by bed, and bed/chair alarms for resident safety and fall prevention. Review of the plan of care (initiated 08/14/21) revealed Resident #32 was at risk for falls. Record review revealed the care plan had not been updated to include Resident #32's fall with fracture (on 10/01/22). The care plan also did not include any of the additional interventions implemented following the fall with fracture including a mat to floor, bed/chair alarms, or C collar. Interview on 10/20/22 at 3:35 P.M. with Registered Nurse (RN) #502 confirmed the plan of care for Resident #32 had not been updated following the resident's fall with fracture. Review of the facility policy titled Care Plan, dated 02/11/08 revealed care plans would be updated on a quarterly basis or when there was a significant change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 11 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21 and a diagnosis of dementia. Residents Affected - Few Review of pressure ulcer risk assessments revealed on 04/07/22, 07/07/22, and 08/11/22 the resident was identified as moderate risk for the development of pressure ulcers. The resident had a physician's order, dated 07/13/21 for weekly skin assessments every Tuesday. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff for bed mobility and transfers and had no pressure ulcers. A plan of care, dated 08/03/21 revealed the resident had a potential for impaired skin integrity related to decreased mobility and diagnosis/disease processes. Interventions included skin checks weekly and as needed. Review of skin sweeps on 09/06/22, 09/13/22, 09/20/22, and 09/27/22 revealed the resident had no pressure ulcers and and bony prominences were without issues. The resident's skin remained intact at present time. No skin breakdown of any type was identified. Record review revealed a physician's order was obtained on 09/24/22 for skin prep (forms a protective film to help reduce friction to the area) to heels at bedtime. There was no reason documented for the order. Review of a skin sweep assessment, dated 09/28/22 revealed the resident had a blister on the right heel measuring 4.2 centimeters (cm) long by 4.0 cm wide. The area was noted to be unstageable (unstageable pressure ulcer: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage III or Stage IV pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur). Record review revealed there was no further description of the area. The assessment noted skin prep was ordered and applied per order. Record review revealed no further documentation of the pressure ulcer to the right heel after 09/28/22. There was no evidence of any monitoring of the area to include measurements, staging, characteristics, progress toward healing, signs of infection, or presence of pain. On 10/08/22 the resident was assessed at high risk for the development of pressure ulcers (after pressure ulcer developed). Weekly skin sweeps on 10/04/22, 10/11/22, and 10/19/22 did not identify any skin issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 12 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/19/22 at 2:05 P.M. observation revealed Resident #28 had a three cm long by 2.5 cm wide red/purple area on the right heel. The skin was intact. Interview with Licensed Practical Nurse #518 at the time of the observation confirmed the presence of the areas. Interview with Acting Director of Nursing #509 on 10/18/22 at 8:30 A.M. confirmed there were no measurements or descriptions of the pressure ulcer to Resident #28's right heel since 09/28/22. She stated she did not know how often the area was to be measured/assessed. Review of the undated facility policy titled Skin Protocol Policy revealed pressure ulcers would be measured by the wound nurse or designee on a weekly basis. Interview with Registered Nurse #502 on 10/20/22 at 3:35 P.M. revealed Resident #28's right heel pressure ulcer had developed on 09/24/22 when the physician's order for treatment was obtained but had no description or measurements until 09/28/22. She confirmed there were no further measurements or descriptions of the area after 09/28/22. She stated weekly measurements were to be done. She confirmed the weekly skin sweeps completed after the development of the pressure ulcer failed to accurately identify the ongoing skin issue. Resident #28 did have a preventative skin plan of care in place prior to development of the heel pressure ulcer with evidence of interventions including heel elevation being provided. The resident was assessed by the wound physician on 10/20/22 who documented the area had healed. The concern identified was related to the lack of evidence the facility was monitoring the ulcer following the development. Based on observation, record review, facility policy review and interview the facility failed to monitor pressure ulcers for healing, complications, or changes in the wound characteristics. This affected two residents (#22 and #28) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date of 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's Disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the care plan, dated 07/08/17 revealed Resident #22 had actual and potential for impaired skin integrity. Interventions included skin checks weekly and as needed. Review of the quarterly MDS 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total dependence from one to two staff for all activities of daily living (ADLs), except eating. The assessment also noted no pressure ulcer areas were reported at the time of the assessment. Review of a skin sweep assessment revealed Resident #22 developed a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer to the coccyx on 09/28/22. There was an additional skin sweep assessment completed on 09/30/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 13 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The assessment revealed the pressure ulcer was a Stage III wound to the coccyx the measured 0.5 centimeters (cm) long and 0.5 cm wide. There was no depth to the wound. The area was noted to be pink and zinc barrier cream was applied per orders. Record review revealed there were no skin assessments completed from 09/30/22 to current (10/20/22). Review of the current physician orders dated October 2022 revealed Resident #22 had an order for a weekly skin assessment on day shift every Friday. Review of progress notes from 09/01/22 to 10/19/22 revealed there were no notes related to the pressure ulcer being assessed or additional measurements. Record review revealed the Resident #22 had preventative skin interventions, including turning and repositioning, which was documented to be provided and the resident compliant with prior to the pressure ulcer development. On 10/20/22 10:40 A.M. observation of Resident #22's skin revealed the coccyx area had two small (less than dime size) areas. One was red and one was crusty with neither area noted to be open. The skin around and on the resident's buttocks was pink. Resident #22 was noted to have an air mattress in place with zinc oxide cream also noted to be intact to the area. Interview on 10/20/22 at 3:45 P.M. with Registered Nurse (RN) #502 confirmed there were not any skin sweeps or assessments/measurements completed to monitor Resident #32's pressure ulcer since 09/30/22. A nursing progress note, dated 10/20/22 at 4:45 P.M. revealed the resident was seen by the wound physician for wound care. The note indicated the coccyx wound site was healing and now smaller in size. The physician recommended to continue zinc ointment for 30 days, continue to off-load, turn and reposition side to side every two hours, except for meals, limit chair time to once daily for one to two hours to promote wound healing. Review of the undated facility policy titled Skin Protocol revealed pressure ulcers would be measured by the wound nurse or designee on a weekly basis. The information would then be placed on the weekly skin report and discussed during the weekly skin meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 14 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21 and a diagnosis of dementia. Residents Affected - Few The resident's plan of care, dated 08/03/21 indicated the resident had potential for nutritional risk related to decreased mobility, diuretics, cognitive deficits, history of cancer, dysphagia, and weight changes. Interventions included obtaining weights as indicated. Review of the MDS 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff with bed mobility and transfers and supervision with eating and had no weight loss. Review of weight records revealed Resident #28 weighed 151 pounds on 09/10/22 and 142.2 pounds on 10/02/22. This represented an 8.8 pound, 5.8% significant weight loss in one month. Review of a nutrition progress note on 10/04/22 revealed the resident had varied meal intakes. Weight noted to be 142 pounds. The note indicated the resident's weight had decreased nine pounds/six percent in 30 days. It was noted the weight loss was significant in 30 days and was noted to be after a seven pound gain (weight was 143.8 pound on 8/22/22). It was noted weight inaccuracies were suspected. A re-weight was requested with weekly weights for closer monitoring. Record review revealed no evidence the resident had been weighed since 10/02/22 when the weight loss was identified. Review of the facility undated policy titled Weight Loss Protocol revealed the procedure could be used to help prevent a significant weight loss from occurring by identifying those residents at an increased risk for weight loss, providing close monitoring of nutritional status, and providing the appropriate interventions. If any weight loss had occurred follow the facility policy and procedure for obtaining accurate weights and re-weights as necessary and again notify the dietician and physician of any significant weight changes. Obtain weekly weights. Appropriate oral supplementation would be provided when deemed necessary. Interview with Registered Nurse #502 on 10/20/22 at 3:50 P.M. confirmed Resident #28 was identified with a significant weight loss 10/02/22. She confirmed a re-weight and weekly weights had not been completed as recommended by the dietician. She confirmed the facility did not follow their policy regarding re-weight and weekly weights. Based on record review, staff interview, and facility policy review, the facility failed to implement nutritional recommendations to prevent or monitor for weight loss for Resident #22 and Resident #28. This affected two residents (#22 and #28) of three residents reviewed for nutrition. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date on 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 15 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care, dated 07/08/17 revealed Resident #22 was at risk for altered nutrition. Interventions included administer medications as ordered and observe for effectiveness, continue to observe weights, labs, oral intakes, and other nutritional parameters with each nutritional review as indicated. Review of resident's weights dated from 07/01/22 to 10/2022 revealed Resident #22 weighed 156 pounds on 10/05/22 and 146 pounds on 10/20/22, a weight loss of five percent since 09/18/22, 7.5% since 07/24/22, and 10% since 04/28/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total dependence from one to two staff for all activities of daily living (ADLs), except eating. The resident required supervision with set up help only with eating. The resident's weight was 159 lbs with no noted weight loss. Review of the current physician orders for October 2022 revealed Resident #22 had the following orders in place: Remeron (anti-depressant) 7.5 milligrams (mg) one tablet daily for weight loss, Arginaid Extra Liquid (nutritional supplement) 240 milliliters (mL) daily to promote weight gain, and Boost VHC Liquid (nutritional supplement) 120 mL twice daily. Review of the nutrition progress note dated 10/04/22 revealed Resident #22 had a weight on 10/02/22 of 144 pounds (lbs). The weight was a decrease of 12 lbs in one week and the note indicated was questionable. The weight loss was significant for one week, 30 days, 90 days, and 180 day time frames. Resident #22 also had a new pressure area develop on 09/28/22. A re-weigh was requested. Registered Dietitian (RD) #592 recommended adding Stress Tab with Zinc and 30 milliliters (mL) liquid protein daily for 30 days. Also recommended an increase of Remeron medication back to 15 milligrams (mg) dose. The recommendations were forwarded to nursing. Review of the nutrition progress note, dated 10/24/22 revealed Resident #22 had a re-weight on 10/05/22 which showed a weight of 156 pounds. On 10/16/22, Resident #22 weighed 142 pounds and on 10/20/22 the resident weighed 146 pounds. The note revealed Resident #22's weights continued to fluctuate. Discussed with nursing to implement nutrition recommendations from 10/04/22. Interview on 10/24/22 at 4:04 P.M. with Registered Dietician (RD) #592 confirmed nutritional recommendations made following the nutritional review on 10/04/22 were not implemented for Resident #22 by the facility staff. The same recommendations were discussed again today (10/24/22) with the Director of Nursing (DON). Interview on 10/24/22 at 6:10 P.M. with the DON confirmed nutritional recommendations made by RD #592 were not implemented and Resident #22 showed additional weight loss upon review today, 10/24/22. Review of the undated facility policy titled Weight Loss Protocol revealed if a significant weight loss occurred place resident on appropriate nutrition interventions based on the results of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 16 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 observation, facility policy review and interview the facility failed to implement an effective infection control program and policies and procedures to prevent the spread of infection including COVID-19 in the facility. This had the potential to affect all 40 residents residing in the facility. Residents Affected - Many Findings include: 1. On 10/17/22 the facility identified 12 residents, Resident #5, #6, #7, #8, #9, #11, #15, #18, #19, #29, #31, #32 who currently had COVID-19 and were in isolation and two residents, Resident #12 and #14 who were symptomatic (of COVID-19) and in quarantine but had tested negative. The resident's rooms were located near or next to the rooms of residents who were not currently positive for COVID-19. On 10/17/22 between 11:26 A.M. and 11:32 A.M. observations revealed Resident #18 and #32's room doors were halfway open with no curtains pulled. Resident #8's room door was open all the way with a curtain pulled across the doorway that had about a three foot gap. Resident #14's room door was open all the way with a curtain pulled across the doorway. On 10/17/22 at 11:38 A.M. Resident #7's door was noted open with no curtain pulled. The resident was visible in the room. On 10/17/22 at 11:43 A.M. Resident #6's room door was noted open with no curtain pulled. The resident was visible in the room. On 10/17/22 at 11:45 A.M. Resident #31's room door was open with no curtain pulled. The resident was visible in the room. The residents had signs on their doors indicating they were on isolation. On 10/18/22 between 10:17 A.M. and 10:22 A.M. observations revealed Resident #6, #31, #9, #15, and #7 had their room doors open without a curtain pulled near doorway. The residents had signs on their doors indicating they were in isolation. On 10/18/22 at 11:01 A.M. Resident #18's door was open. On 10/18/22 at 11:03 A.M. Resident #32's door was open. On 10/18/22 at 11:06 A.M. Resident #19's door was open. These residents were in isolation for COVID-19. Interview with Acting Director of Nursing (DON) #509 on 10/18/22 at 11:28 A.M. revealed all residents on isolation/quarantine for COVID-19 should have their room doors closed unless it was a safety issue for the resident. She stated she was not aware if there were any residents who could not have their door closed. She stated the Administrator was in charge of that. Interview with the Administrator on 10/18/22 at 1:32 P.M. revealed it was the DON's responsibility to determine if a resident couldn't have their door closed during COVID-19. The facility later provided a list of five residents who were in isolation or quarantine for COVID (Residents #7, #11, #14, #18, and #32) who were not safe to have their door closed. Signs were then added to their doors indicating not to close door. Review of the facility undated policy titled COVID-19 Policy/Procedure revealed under residents with known COVID-19 infection isolation and management always ensure resident stays in resident room with door closed if possible. 2. On 10/18/22 at 8:25 A.M. observation revealed the Administrator took a meal tray into the room of Resident #42 (not positive for COVID). Although there was an outbreak of COVID-19 in the facility, the Administrator was not wearing any eye protection in the resident room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 17 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview with the Administrator on 10/18/22 at 8:25 A.M. confirmed she should have worn eye protection into the resident room. Observation on 10/18/22 at 10:54 A.M. revealed Therapy Director #584 was in the therapy gym. She was standing in front of Resident #10 (not positive for COVID) who was receiving therapy and was not wearing any eye protection. Interview with Therapy Director #584 on 10/18/22 at 10:54 A.M. confirmed she was not wearing any eye protection and should have. She stated she forgot. Interview with the Administrator on 10/19/22 at 10:30 A.M. revealed staff were to wear eye protection while providing direct care to residents. She stated this was per the Centers for Disease Control (CDC) Guidance the facility was following, which she indicated she would provide for review. Review of the information provided from the Centers for Disease Control and Prevention titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, updated 09/23/22 revealed facilities located in counties where Community Transmission was high should consider having health care personnel use eye protections during all patient care encounters. (The facility was identified in a county with substantial community transmission rate and was in outbreak status within the facility at the time of the observations). Review of the facility undated policy titled Policy and Procedure for Use of and Disinfecting Face Shields and Goggles revealed face shields/goggles would be worn while providing direct patient care when our county transmission was red (high) and during a Covid outbreak. 3. Observation on 10/17/22 at 11:32 A.M. revealed State Tested Nursing Assistant (STNA)#546 applied personal protective equipment (PPE) to enter the room of Resident #14 who was in isolation precautions due to being symptomatic for COVID-19 (tested negative). STNA #546 was observed to put an N95 mask over top of the N95 mask she was already wearing (double mask). When she exited the room she removed only the top N95 mask and continued to wear the other N95 mask that she had worn into the room. Interview with STNA #546 at the time of the observation confirmed she wore two N95 masks into the room and only removed the top one when leaving the room. The sequence for putting on and taking off PPE was posted on Resident #14's door. It stated to apply a mask upon entering the room and remove the mask and discard upon leaving the room. Interview with Acting Director of Nursing #509 on 10/19/22 at 10:05 A.M. revealed staff were not to apply two N95 masks. She stated staff should wear one N95 mask into the room and change it upon leaving the room. 4. Observation on 10/18/22 at 3:40 P.M. revealed Licensed Practical Nurse #518 and Therapy Director #584 applied PPE to enter Resident #7's room (positive for COVID-19). Both staff applied a surgical mask over top of the N95 mask they were wearing before entering the room. When Therapy Director #584 left the room, she removed the surgical mask but did not change the N95 mask she had worn into the room. Interview with Therapy Director #584 at the time of the observation confirmed she had worn a surgical mask over the N95 mask and only removed the surgical mask and did not change the N95 mask. Interview with Acting Director of Nursing #509 on 10/19/22 at 11:07 A.M. revealed staff should not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 18 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete put a surgical mask over the N95 mask prior to going into an isolation room. She stated staff should wear an N95 mask and change it upon leaving the room. Review of the undated facility COVID-19 Policy/procedure revealed all staff were to wear appropriate PPE when caring for a resident with known COVID-19 infection. Prior to entering isolation room, apply clean N95 mask, gown, gloves, eye protection. Prior to exiting remove all PPE and obtain clean N95 mask outside isolation room door. Event ID: Facility ID: 366016 If continuation sheet Page 19 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of infection line listing reports, facility policy review and interview the facility failed to ensure antibiotic use protocols were followed to ensure the appropriate use of antibiotics. This affected two residents (#1 and #16) of two residents reviewed for urinary tract infections/antibiotic use. Residents Affected - Few Findings include: 1. Review of the facility infection line listing report for August 2022 revealed one resident, Resident #1 was identified to have urinary tract infection. The listing report noted the resident was treated with antibiotics. However, the facility had no documentation the antibiotic use had been reviewed and met the criteria for appropriate antibiotic use (urine culture with >100,000 bacteria and symptomatic). Review of the medical record for Resident #1 revealed an admission date of 06/27/22. On 08/11/22 at 10:15 A.M. a nurse's note revealed the physician was in. The resident had increased confusion, dysuria, and foul smelling urine. New orders were obtained for a urinalysis and culture and sensitivity of the urine. Urine culture results on 08/14/22 indicated a urinary tract infection with >100,000 Klebsiella Pneumoniae. On 08/15/22 an antibiotic, Macrobid was started at 100 milligrams daily for seven days. On 08/18/22 the antibiotic was increased to twice daily for the next four days. The medication was given as ordered. Interview with Acting Director of Nursing (DON) #509 on 10/26/22 at 9:25 A.M. revealed she was not aware of how the facility documented antibiotic use met the criteria for appropriate use. A follow-up interview on 10/26/22 at 1:43 P.M. revealed the DON confirmed in the past three months antibiotic surveillance tracking forms had not been used per policy. She stated the facility had used the McGeer criteria for determining infections met surveillance criteria. However, she confirmed these had not been used in the past three months. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Orders for Antibiotics revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy revealed appropriate indications for use of antibiotics included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial. When a culture and sensitivity was ordered, it would be completed. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes revealed the Infection Preventionist or designee would review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that were not consistent with the appropriate use of antibiotics. All resident antibiotic regimens would be documented on the facility approved antibiotic surveillance tracking form. The information gathered would include: Resident name, room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, adverse events. 2. Review of the facility infection line listing report for September 2022 revealed one resident, Resident #16 with a urinary tract infection was identified and one resident (#16) with antibiotic use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 20 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0881 Level of Harm - Minimal harm or potential for actual harm for a urinalysis only. The line listing report noted the resident was treated with antibiotics. However, the facility had no documentation the antibiotic use had been reviewed and met the criteria for appropriate antibiotic use (urine culture with >100,000 bacteria and symptomatic). Review of the medical record for Resident #16 revealed an admission date of 07/22/22. Residents Affected - Few Review of a nurse's note revealed on 09/06/22 at 10:35 A.M. the physician assistant was in. The resident had complaints of dysuria with foul smelling urine. A new order was received to obtain a urinalysis with culture and sensitivity of the urine. On 09/08/22 at 9:34 A.M. nurse's notes indicated the urinalysis results were reviewed with the physician and a new order was received for an antibiotic, Macrobid 100 milligrams twice daily for seven days. There was no evidence a culture and sensitivity was done to determine if a urinary tract infection was present. Review of the medication administration record revealed the antibiotics were given as ordered. Interview with Acting Director of Nursing (DON) #509 on 10/26/22 at 9:25 A.M. revealed she was not aware of how the facility documented antibiotic use met the criteria for appropriate use. A follow-up interview on 10/26/22 at 1:43 P.M. revealed the DON confirmed in the past three months antibiotic surveillance tracking forms had not been used per policy. She stated the facility had used the McGeer criteria for determining infections met surveillance criteria. However, she confirmed these had not been used in the past three months. During the interview with Acting Director of Nursing #509 on 10/26/22 at 1:43 P.M., the DON confirmed a urine culture and sensitivity was not completed for Resident #16. She stated she did not know why. She confirmed the antibiotics were prescribed based on the urinalysis, which showed elevated white blood cells. She confirmed this would not meet the criteria for appropriate antibiotic use without a culture and sensitivity. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Orders for Antibiotics revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy revealed appropriate indications for use of antibiotics included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial. When a culture and sensitivity was ordered, it would be completed. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes revealed the Infection Preventionist or designee would review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that were not consistent with the appropriate use of antibiotics. All resident antibiotic regimens would be documented on the facility approved antibiotic surveillance tracking form. The information gathered would include: Resident name, room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, adverse events. There was no evidence antibiotic surveillance tracking forms had been utilized in the past three months or that antibiotic use was evaluated to determine it met the criteria for appropriate use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 21 of 22 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 366016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Terrace Care Center 1318 E Main Street Lancaster, OH 43130 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on record review, facility policy review and interview the facility failed to ensure the designated Infection Preventionist, Registered Nurse #504 worked at least part-time and was involved in the Quality Assessment and Assurance Program to report on the facility Infection Control and Prevention Program. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) Committee documentation revealed the facility identified Infection Preventionist, Registered Nurse #504 was not a member of the committee. Interview on 10/17/22 at 10:01 A.M. with the Administrator and Business Office Manager (BOM) #555 revealed the facility was currently in a COVID-19 outbreak. The facility had 13 residents and one staff who had confirmed positive tests for COVID-19. The facility had an additional two residents who had tested negative for COVID-19 but were displaying signs and symptoms of the virus. On 10/25/22 at 12:37 P.M. telephone interview with Infection Preventionist(IP)/Registered Nurse (RN) #504 revealed the facility was currently searching for another IP because she had started working as a floor nurse full time about three months ago. Prior to going back to working as a floor nurse, RN #504 stated she only worked one day a week on Fridays and picked up one shift on a weekend a month because she had small children to care for at home. RN #504 stated she was not working part-time hours. RN #504 confirmed she was still the acting IP for the facility at this time. RN #504 revealed the Director of Nursing (DON) prior to the current DON had started taking training courses to become the new IP, but had not completed the coursework before she quit working at the facility. RN #504 revealed the facility had two outbreaks of COVID-19 in the last year. RN #504 stated the Administrator was in charge of most of the oversight of the facility's Infection Control and Prevention programs and procedures. Interview on 10/25/22 at 4:10 P.M. with the Administrator confirmed RN #504 was the facility current IP. The Administrator confirmed RN #504 had not been overseeing the facility's infection control and prevention programs and procedures due to working as a floor nurse. The Administrator confirmed she had been overseeing the facility's infection control programs since the previous DON quit, but stated she (the Administrator) was not a certified IP. The Administrator confirmed part-time hours would equal 20 to 25 hours per week and RN #504 only worked on Fridays and one day on one weekend of a month prior to working full-time as a floor nurse. The Administrator also confirmed RN #504 was not a member of the Quality Assurance (QA) Committee and did not attend QA meetings regularly. Review of the facility policy titled Infection Preventionist, revised 07/2016 revealed the Infection Preventionist shall coordinate the development and monitoring of our facility's established infection prevention and control policies and practices. The Infection Preventionist shall report information related to compliance with our facility's established infection prevention and control policies and practices to the Administrator and Quality Assurance and Performance Improvement Committee (QAPI). The Infection Preventionist shall keep abreast of changes in infection prevention and control guidelines and regulations to ensure our facility's protocols remain current and aid in preventing and controlling the spread of infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366016 If continuation sheet Page 22 of 22