Health inspection·February 15, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting the right dominant side, epilepsy, neuromuscular dysfunction of the bladder, unspecified dementia with behavioral disturbance, schizophrenia, panic disorder, and hypothyroidism. Residents Affected - Few Review of the MDS assessment, dated 11/7/23, revealed the resident was severely cognitively impaired and dependent for toileting and mobility. Review of the most recent care plan revealed Resident #4 had ADL deficiencies and was encouraged to use the bell to call for assistance. Observation on 02/12/24 at 8:58 P.M. revealed Resident #4 was in a wheelchair in the middle of the resident room with the call light out of reach. The call light was clipped to the resident's bed which was more than six feet from the resident. Interview on 02/12/24 at 9:00 P.M. with Registered Nurse (RN) #206 verified Resident #4 was dependent for care and confirmed the call light was out of the resident's reach. RN #206 stated the resident did not have means to reach the call light, and verified Resident #4 did use the call light for assistance at times. Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure timely response to activated call lights and failed to ensure call lights were within reach of residents who were capable of using the call light and were dependent for care. This affected two (#1 and #4) of three residents reviewed for call lights. The facility census was 75. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 05/16/95 with diagnoses of hemiplegia and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and was dependent on staff for toileting. Review of the current care plan revealed Resident #1 had an activities of daily living (ADL) self-care deficit due to left side hemiplegia. Interventions included to provide a bedpan or bedside commode. Interview and observation on 02/12/24 at 7:30 P.M. with State Tested Nurse Aide (STNA) #315 confirmed the call light system was linked to a computer monitor showing the length of time a call light was active. STNA #315 also indicated the call light system was unreliable and at times, call lights would continue to display as active on the monitor after staff provided care to a resident and turned off the call light. STNA #315 confirmed the call light monitor had an audible ring when a call light was active. Interview on 02/12/24 at 8:24 P.M. with Resident #1 revealed concerns regarding the functioning of her call light and wait times of 45 minutes to an hour for a response from staff to answer her call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 2 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm light. Resident #1 stated she would yell to get staff attention and confirmed they would respond to her yelling. Observation on 02/14/24 at 10:19 A.M. of the call light monitor revealed the call in Resident #1's room was active for 22 minutes and the monitor was ringing. Residents Affected - Few Interview on 02/14/24 at 10:20 A.M. with Resident #1 revealed she needed to use the bathroom and was waiting for a bedpan. Resident #1 said her call light had been on a while. Observation on 02/14/24 at 10:21 A.M. revealed Certified Medication Aide (CMA) #296 standing at a medication cart facing the back of the call light monitor. The call light monitor was ringing. Observation on 02/14/24 at 10:28 A.M. revealed Licensed Practical Nurse (LPN) #240 at the nurses' station where the call light monitor was ringing. LPN #240 left the nurses' station to assist CMA #296 with Resident #52 in his room. Observation on 02/14/24 at 10:29 A.M. revealed the Director of Nursing (DON) and an unidentified STNA entered another resident room as the call light monitor continued to ring. Observation from the nurses' station on 02/14/24 at 10:30 A.M. revealed a resident was heard calling out, Hey., and continued observation revealed the DON and the unidentified STNA walked down the hall into another resident room. Observation on 02/14/24 at 10:32 A.M. revealed Resident #1's door remained open. Interview at that time with Resident #1 confirmed she was the resident who called out for assistance. No staff were visible during the observation. Observation on 02/14/24 at 10:35 A.M. revealed Registered Nurse (RN) #297, LPN #240, and RN #266 standing near the nurses' station engaged in conversation as the call light monitor continued to ring. RN #297, LPN #240, and RN #266 did not look at the call light monitor. Continued observation revealed RN #266 left the nurses' station and entered her office. Observation on 02/14/24 at 10:36 A.M. revealed Resident #1's door remained open. Observation on 02/14/24 at 10:37 A.M. revealed the sound of a resident calling, Hey. A concurrent observation revealed RN #297 and LPN #240 walking down the hall. Observation on 02/14/24 at 10:37 A.M. revealed LPN #240 entered Resident #1's room and closed the door. Observation on 02/14/24 at 10:38 A.M. revealed the call light monitor displayed Resident #1's call light was active for 41 minutes. Interview at that time, with concurrent observation of the call light monitor with RN #297, confirmed the display read Resident #1's call light was active for 41 minutes. RN #297 further stated the call light monitor was not reliable regarding the length of time call lights were active. Interview on 02/14/24 2:15 P.M. with the DON revealed she conducted paper call light audits throughout the facility on different shifts. The DON stated she would either activate a call light and document the time it took staff to respond or if she observed an active call light she would monitor the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 3 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 length of time it took staff to respond. However, the DON stated after seven minutes she would answer the call light herself because she did not want residents to wait too long for care. 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: 365101 If continuation sheet Page 4 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure advanced directives were consistent throughout the medical record. This affected one (#49) of 24 residents reviewed for advanced directives. The facility census was 75. Findings include: Review of the medical record for Resident #49 revealed an admission date of 12/08/23 with diagnoses of Alzheimer's disease and vascular dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severely impaired cognition. Review of the electronic medical record (EMR) revealed Resident #49 had a physician order for Do Not Resuscitate Comfort Care (comfort measures to be administered before, during, or after the time of cardiac or respiratory arrest). Interview on 02/13/24 at 4:39 P.M. with Registered Nurse (RN) #297 confirmed there was a paper copy of Resident #49's advance directive in her paper medical record. The paper copy revealed Resident #49's code status was Do Not Resuscitate Comfort Care - Arrest (permits the use of life-saving measures before a person's cardiac or respiratory arrest; however, only comfort care may be provided after a person's heart or breathing stops). RN #297 confirmed Resident #49's advanced directives in the EMR and the paper medical record did not match. A follow-up interview with RN #297 on 02/13/24 at approximately 5:00 P.M. confirmed Resident #49's advance director order was incorrect in the EMR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 5 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #71 revealed an admission date of 10/13/23 with diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and nicotine dependence. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed Resident #71 had intact cognition and used oxygen. Review of the current physician order dated 10/13/23 revealed Resident #71 received oxygen continuously through a nasal cannula. Review of the current physician order dated 10/13/23 revealed Resident #71's oxygen tubing and filter should be changed every week. Documentation should include the number of minutes required to complete the task. Review of the December 2023 and January and February 2024 treatment administration records (TARs) for Resident #71 revealed staff completed the order for changing the oxygen tubing and filter on 12/03/23, 12/10/23, 12/17/23, 12/24/23, 12/31/23, 01/07/24, 01/14/24, 01/21/24, 02/04/24, and 02/11/24. Observation on 02/13/24 at 9:09 A.M. revealed Resident #71 was in bed receiving oxygen via nasal cannula. Observation of the oxygen tubing revealed a piece of tape with the date 11/29/23. Interview with Resident #71 during the observation reported no concerns with his care. Observation on 02/13/24 at 4:36 P.M. revealed Resident #71 lying in bed receiving oxygen via nasal cannula with a piece of tape dated 02/13/24. Interview at that time with Resident #71 revealed his oxygen tubing was changed when he was out of the room and does not know who changed it. Interview on 2/13/23 at 4:43 P.M. with Licensed Practical Nurse (LPN) #240 confirmed she changed Resident #71's oxygen tubing. Additionally, LPN #240 confirmed the tubing she removed from his room was dated November 2023. 3. Review of the medical record for Resident #74 revealed an admission date of 11/13/23 with diagnoses of acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #74 had intact cognition and received oxygen. Review of the current physician orders for Resident #74 revealed he received oxygen at two liters per minute via nasal cannula continuously since 11/13/23. Review of the current physician order dated 11/13/23 revealed Resident #74's oxygen tubing/filter should be changed every week. Documentation should include the number of minutes required to complete the task. Review of the December 2023 and January and February 2024 TARs for Resident #74 revealed staff completed the order for changing the oxygen tubing and filter on 12/03/23, 12/10/23, 12/17/23, 12/24/23, 12/31/23, 01/07/24, 01/14/24, 01/21/24, 02/04/24, and 02/11/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 6 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/13/24 at 8:27 A.M. revealed Resident #74 sitting up in bed receiving oxygen via nasal cannula. Additional observation revealed a length of tubing with a piece of tape wrapped around it dated 11/29/23. Observation and interview with RT #278 on 02/13/24 at 8:42 A.M. confirmed Resident #74's oxygen tubing was dated 11/29/23 and should have been replaced. Further observation revealed the oxygen tubing was extender tubing between the oxygen concentrator and the nasal cannula tubing. Interview on 02/13/24 at 4:44 P.M. with Unit Manager, RN #297, confirmed oxygen tubing should be changed weekly by the floor nurse. Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure only physician ordered tracheostomy supplies were readily available to staff for respiratory needs, and failed to ensure supplemental oxygen tubing was changed as ordered. This affected three (#71, #74, and #76) of four residents reviewed for respiratory care. The facility census was 75. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 11/16/23. Diagnoses included cerebral palsy, spastic quadriplegia, hypertension, dysphagia, end stage renal disease with dependence on dialysis, and respiratory failure with hypercapnia and dependence on a respirator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was assessed with cognitive impairment with memory loss. Resident #76 was dependent on staff for all care and required oxygen therapy and suctioning via tracheostomy (a surgical airway passage into the trachea). Review of the care plan dated 12/01/23 revealed Resident #76 had a tracheostomy related to respiratory failure. Interventions included tracheostomy ties secured at all times, oxygen settings per continuous aerosol tracheostomy collar (CATC) as tolerated, suction as necessary, and tube out procedures that included extra tracheostomy tube and obturator at bedside. Review of the current physician orders for Resident #76 revealed a size six flex cuffed tracheostomy was to be changed every month, tracheostomy care each shift and as needed, CATC as tolerated, suction tracheostomy as needed. Observation on 02/14/24 at 8:30 A.M. revealed Resident #76 was laying in bed on right side with eyes open and followed movement in room. Three boxes of cuffed tracheostomies sat on the window ledge to the right of Resident #76, two boxes were labeled size six and one was labeled a size four. Additional observation on 02/14/24 at 11:10 A.M. revealed the two size six flex cuffed tracheostomy boxes and one size four flex cuffed tracheostomy box remained on the window ledge to the right of Resident #76. Interview on 02/14/24 at 11:15 A.M. with Respiratory Therapist (RT) #262 verified Resident #76 required a size six cuffed tracheostomy and further verified the size four on the window ledge should not be in Resident #76's room and removed the size four tracheostomy from the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 7 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled, Trach Care, stated a complete physician's order was required including the frequency of care to ensure the provision of safe and quality care to all residents requiring tracheostomy care and all tracheostomy care was performed by respiratory therapy personnel. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 8 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, staff interview, pharmacy staff interview, and review of a pharmacy agreement document, the facility failed to ensure irregularities were identified during monthly drug regimen reviews and those irregularities were reported to the facility. This affected one (#20) of six residents reviewed for pharmacy monthly drug regimen reviews. The facility census was 75. Findings include: Review of the medical for Resident #20 revealed an admission date of 03/24/20 with a diagnosis of hypokalemia (low potassium). Review of Resident #20's physician orders revealed the resident was ordered the supplement potassium tablet 20 milligrams (mg) in December 2023, January 2024, and currently in February 2024. Review of the monthly physician progress notes for Resident #20 for December 2023 and January and February 2024 the physician reviewed the medication list for Resident #20 which included an order for potassium tablet 20 mg and contained a plan to continue the potassium supplement. Review of the monthly medication regimen review (MRR) documents for Resident #20 for November and December 2023 and January 2024 revealed completed medication reviews by the pharmacist with no recommendation for an appropriate order for the potassium tablet 20 mg. Interview on 02/14/24 at 9:40 AM with the Director of Nursing (DON) stated medications are signed off monthly by the physician in the monthly physical as the monthly review. The DON stated the nurse who obtained an order was responsible for ensuring the orders are correct and entered into the system. The DON further stated all new orders are reviewed by the DON, unit managers, and the Minimum Data Set (MDS) nurse. The DON verified Resident #20's order for potassium tablet 20 mg was an inaccurate order as potassium was prescribed in milliequivalent (mEq) units of measure. Interview on 02/14/24 at 11:03 A.M. with Pharmacist Consultant (PC) #351 stated he completed monthly reviews onsite and if recommendations are made these are provided to the DON. PC #351 stated, If I was looking at potassium, I would look at potassium 20 and would not pay attention to mgs versus mEq and move on because potassium is dispensed in mEq. Further interview with PC #351 stated there was a difference between mg and mEq in unit of measure for potassium. Interview on 02/14/24 at 11:40 A.M. with Pharmacist #350 stated the consultant company completed the monthly reviews at the facility and reports any suggestions for recommendations to the facility. Pharmacist #350 stated doses of potassium in mgs did not exist. Pharmacist #350 further stated the original order for Resident #20's potassium 20 mg was clarified at the pharmacy by the nurse as 20 mEq, and the pharmacy was not responsible for changing the medication administration record (MAR) at the facility. Review of the Clinical Pharmacist Services Agreement dated 09/21 revealed the services rendered by the consulting pharmacist was to perform a comprehensive medication regimen review of each facility resident at least monthly and report in writing any irregularities, deviations, or unusual occurrences to the facility's Executive Director, Medical Director, DON, and/or where appropriate the residents attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 9 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of pharmacy packing slips, review of a pharmacy provider agreement, and review of a facility policy, the facility failed to ensure medications were available and administered as ordered by the physician resulting in significant medication errors. This affected one (#77) of two residents observed during medication administration and two (#76 and #331) of five residents reviewed for medications. The facility census was 75. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #76 revealed an admission date of 11/16/23. Diagnoses included cerebral palsy, spastic quadriplegia, hypertension, dysphagia, end stage renal disease with dependence on dialysis, and respiratory failure with hypercapnia with dependence on a respirator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was assessed with cognitive impairment with memory loss, was dependent on staff for all care, was dependent on supplemental oxygen, and had a intravenous (IV) line. Review of the physician orders for Resident #76 revealed an order written on 02/09/24 for anti-seizure medication Phenobarbital 30 milligrams (mg) one tablet per gastrostomy tube (artificial opening to the stomach) each morning and one tablet per gastrostomy tube at bedtime to start on 02/09/24 at 8:00 P.M. Further review revealed a physician order written on 02/09/24 for the antifungal micafungin sodium 100 milliliters (ml) reconstituted IV each morning for candida infection for three days, and to start on 02/10/24. Review of the mediation administration record (MAR) for February 2024 revealed Resident #76's Phenobarbital 30 mg administration started on 02/14/24. The MAR indicated Phenobarbital was unavailable on 02/09/24 at 8:00 P.M., 02/10/24, 02/11/24, and 02/12/24. Resident #76's micafungin sodium 100 mls was administered once on 02/12/24. Interview on 02/15/24 at 2:15 P.M. with the Director of Nursing (DON) verified Resident #76's Phenobarbital and micafungin sodium was not available from the pharmacy and further verified the medications were not administered as ordered. Interview on 02/15/24 at 2:20 P.M. with Infection Control Registered Nurse (ICRN) #297 revealed a daily review of resident treatments are completed, and if there are missed doses of medications for a resident treatment for infection, the physician was notified and an order was received to adjust and extend the medication administration to ensure the resident received the full regimen of the prescribed treatment. ICRN #297 verified the micafungin sodium for Resident #76 was not adjusted and further verified the resident only received one day of a three day prescribed treatment. Review of facility provided pharmacy packing slips revealed the Phenobarbital for Resident #76 was received by the facility on 02/13/24, and the micafungin sodium for Resident #76 was received by the facility on 02/09/24. 2. Review of the medical record for Resident #331 revealed an admission date of 02/10/24. Diagnoses included acute subacute infection endocarditis, chronic stage three kidney disease, dependence on renal dialysis, heart disease, heart failure, chronic obstructive pulmonary disease, hypertension, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 10 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 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 0760 type II diabetes mellitus, cardiomyopathy, aortic valve replacement, and endocarditis. Level of Harm - Minimal harm or potential for actual harm Review of the admission physician orders written on 02/10/24 revealed Resident #331 had an order for the antibiotic ampicillin sodium two grams IV every eight hours for bacterial endocarditis for 36 administrations until finished. Residents Affected - Few Review of Resident #331's MAR for February 2024 revealed the ampicillin sodium was not administrated on 02/10/24 at 6:00 A.M., 4:00 P.M., and 02/11/24 at 12:00 A.M. Interview on 02/15/24 at 2:15 P.M. with the DON verified the missed doses of Resident #331's ampicillin sodium on 02/10/24 and 02/11/24. Interview on 02/15/24 at 2:20 P.M. with ICRN #297 also verified Resident #331 missed the antibiotic doses on 02/10/24 and 02/11/24. ICRN #297 stated she had no knowledge of the missed doses until 02/15/24. 3. Review of the medical record for Resident #77 revealed an admission date of 01/10/24 with diagnoses of a left lower leg fracture and fracture of the sacrum. Review of the care plan dated 01/10/24 for Resident #77 revealed she was care planned for pain related to a left lower leg fracture with an intervention to administer pain medication and report symptoms of uncontrolled pain. Review of a physician order dated 01/11/24 revealed Resident #77 was ordered the pain medication naproxen 500 mg. Review of the nursing progress notes notes for Resident #77 dated 02/14/24 revealed the naproxen was not available for administration. Observation and interview on 02/14/24 at 8:45 A.M., with Licensed Practical Nurse (LPN) #318 during medication administration, verified Resident #77's naproxen 500 mg was not available for administration in the medication cart or in the automated dispensing unit (unit that holds commonly used medications for administration). Review of the facility policy titled, Administering Medications, revised 04/19, revealed medications are administered in accordance with prescriber orders, including any required time frame. Review of the Pharmacy Provider Agreement commencing on 09/01/01, and signed on 07/28/21, revealed the pharmacy shall arrange for all new admissions, orders, and routine reorders to be delivered by the pharmacy to meet the needs of the resident. Additionally, the contract stated if the facility requested a non-emergent medication as an immediate order the pharmacy may make arrangements with another pharmacy (back-up pharmacy) to provide an ordered pharmacy product in limited supply to ensure the appropriate care and treatment of a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 11 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (#8 and #53) of four residents reviewed for medication storage. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included unspecified injury at the C5 level of cervical spinal cord, quadriplegia, chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease with heart failure, and type two diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 12/22/23, revealed Resident #8 was cognitively intact. Review of the most recent care plan revealed Resident #8 had depression due to physical limitations. Interventions included to administer medications as order and monitor/document for side effects and effectiveness. The resident declines medications due to paranoia at times and often thinks staff are talking about him, so staff are to reassure as needed. Review of physician orders, dated 02/14/24, revealed Resident #8's morning medications included the antibiotics amoxicillin-potassium clavulanate oral tablet 875-125 milligrams (mg) and Hiprex 1 gram (gm) by mouth, the pain medication aspirin capsule 81 mg by mouth, the muscle relaxer baclofen tablet 10 mg by mouth, the supplements cholecalciferol tablet 25 micrograms (mcg), ferrous sulfate tablet 325 mg, magnesium oxide tablet 400 mg, multivitamin tablet, potassium chloride extended release tablet 20 milliequivalent (meq) by mouth, and the medication to treat gastroesophageal reflux disease pantoprazole sodium tablet delayed release 20 mg by mouth. Review of the medication self-administration safety screen, dated 06/30/19, revealed the resident may not self- administer medications. Observation on 02/13/24 at 9:13 A.M. revealed two clear plastic medication cups on Resident #8's bedside table. One medication cup was approximately one-third to one-half full with various pills and the other had white round pills. Interview on 02/13/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #326 verified she left Resident #8's medications at the bedside stating the resident preferred to take the medication after breakfast. LPN #326 did not know if Resident #8 was assessed to self- administer medication. LPN #326 stated one medication cup was Resident #8's morning medications and the other with the white round pills were for gas. 2. Review of the medical record for Resident #53 revealed an admission date of 09/30/23 with diagnoses of esophageal cancer and gastrointestinal reflux disease (GERD). Review of the quarterly MDS assessment dated [DATE] revealed Resident #52 is cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 12 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current physician orders dated February 2024 for Resident #53 revealed an order for pantoprazole sodium 40 milligrams (mg). Observation on 02/14/24 at 7:43 A.M. revealed LPN #314 left her medication cart to administer already prepared medications for administration. LPN #314 left, unattended, one yellow, oblong pill that was stamped with I52 on the pill in a plastic medication cup on top of the medication cart. Observation on 02/14/24 at 7:45 A.M. revealed LPN #314 returned to her medication cart and verified she left the yellow, oblong pill unattended on top of her medication cart. LPN #314 verified the medication she left unattended was pantoprazole sodium 40 mg and that medication was for Resident #53. Review of the facility policy titled, Storage of Medications, revised 04/19, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 13 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review, the facility failed to ensure the electronic medical record (EMR) accurately reflected physician orders and treatments provided to residents. This affected four (#49, #71, #74, and #77) of 20 residents reviewed for an accurate medical record. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #77 was admitted on [DATE]. Diagnoses included encounter for other orthopedic aftercare, other fracture of the left lower leg, subsequent encounter for closed fracture with routine healing, nontraumatic subarachnoid hemorrhage, unspecified fracture of the sacrum initial encounter for closed fracture, lesion of the radial nerve of the left upper limb, and cutaneous abscess of the left lower limb. Review of the Minimum Data Set (MDS) assessment, dated 01/17/24, revealed the resident was cognitively intact. Review of Resident #77's physician order, dated 01/10/24 to 02/13/24, revealed an order for normal saline flush solution 0.9 percent (%), use 10 milliliters (mls) intravenously every 12 hours for maintenance flush to maintain patency, flush 10 mls of normal saline followed by five (5) mls of heparin (10 units per ml) every 12 hours for every unused lumen and as needed as clinically indicated. Heparin administration to be documented in a separate order. Further review of physician orders revealed no additional order for heparin. Review of the medication administration record (MAR) dated January and February 2024, revealed Resident #77's normal saline flush was documented as ordered; however, the heparin was not documented in a separate order. Interview on 02/14/24 at approximately 10:45 A.M. with the Director of Nursing (DON) verified Resident #77's heparin order was never included as an additional order, and therefore, was not documented on the MARs as indicated. 2. Review of the medical record for Resident #49 revealed an admission date of 12/08/23 with diagnoses of Alzheimer's disease and vascular dementia. Review of the comprehensive admission MDS assessment dated [DATE] revealed Resident #49 had severely impaired cognition and did not receive oxygen therapy. Review of the current physician order dated 12/07/23 revealed Resident #49 received oxygen continuously through a nasal cannula. Review of the current physician order dated 12/07/23 revealed Resident #49's oxygen tubing and filter should be changed every week. Documentation should include the number of minutes required to complete the task. Review of Resident #49's treatment administration record (TAR) for December 2023, January 2024, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 14 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some February 2024 revealed no documentation regarding the administration of oxygen or the oxygen tubing being changed. Observation on 02/12/23 at 8:47 P.M. revealed Resident #49 lying in bed with a nasal cannula on the mattress next to her. Continued observation revealed State Tested Nurse Aide (STNA) #307 assisting Resident #49 to reapply the nasal cannula. No date was observed on the oxygen tubing. Interview on 02/13/24 at 4:53 P.M. with Registered Nurse (RN) #297 and the DON confirmed Resident #49's orders for oxygen administration and changing of the oxygen tubing did not generate on the TAR. Further interview confirmed the orders were entered in such a way as the nurse assigned to Resident #49 was not prompted to verify oxygen was in place and was not prompted to change the oxygen tubing. Therefore, the electronic medical record could not verify Resident #49 consistently received oxygen or the tubing was changed. 3. Review of the medical record for Resident #71 revealed an admission date of 10/13/23 with diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and nicotine dependence. Review of the quarterly MDS assessment dated [DATE] revealed Resident #71 had intact cognition and used oxygen. Review of the current physician order dated 10/13/23 revealed Resident #71 received oxygen continuously through a nasal cannula. Review of the current physician order dated 10/13/23 revealed Resident #71's oxygen tubing and filter should be changed every week. Documentation should include the number of minutes required to complete the task. Review of the December 2023, January 2024, and February 2024 TAR for Resident #71 revealed staff documented completing the order for changing the oxygen tubing and filter on 12/03/23, 12/10/23, 12/17/23, 12/24/23, 12/31/23, 01/07/24, 01/14/24, 01/21/24, 02/04/24, and 02/11/24. Observation on 02/13/24 at 9:09 A.M. revealed Resident #71 in bed receiving oxygen via nasal cannula. Observation of the oxygen tubing revealed a piece of tape with the date 11/29/23. Observation on 02/13/24 at 4:36 P.M. revealed Resident #71 lying in bed receiving oxygen via nasal cannula with a piece of tape dated 02/13/24. Interview at that time with Resident #71 revealed his oxygen tubing was changed when he was out of the room and does not know who changed it. Interview on 02/13/23 at 4:43 P.M. with Licensed Practical Nurse (LPN) #240 confirmed she changed Resident #71's oxygen tubing. Additionally, LPN #240 confirmed the tubing she removed from his room was dated November 2023. 4. Review of the medical record for Resident #74 revealed an admission date of 11/13/23 with diagnoses of acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #74 had intact cognition and received oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 15 of 16 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 365101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Nursing and Rehabilitation Center LLC 401 N Broadway St Green Springs, OH 44836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the current physician orders for Resident #74 revealed he received oxygen at two liters per minute via nasal cannula continuously since 11/13/23. Review of the current physician order dated 11/13/23 revealed Resident #74's oxygen tubing/filter should be changed every week. Documentation should include the number of minutes required to complete the task. Review of the December 2023, January 2024, and February 2024 TAR for Resident #74 revealed staff documented completing the order for changing the oxygen tubing and filter on 12/03/23, 12/10/23, 12/17/23, 12/24/23, 12/31/23, 01/07/24, 01/14/24, 01/21/24, 02/04/24, and 02/11/24. Observation on 02/13/24 at 8:27 A.M. revealed Resident #74 sitting up in bed receiving oxygen via nasal cannula. Additional observation revealed a length of tubing with a piece of tape wrapped around it dated 11/29/23. Observation and interview with Respiratory Therapist (RT) #278 on 02/13/24 at 8:42 A.M. confirmed Resident #74's oxygen tubing was dated 11/29/23 and should have been replaced. Further observation revealed the oxygen tubing was extender tubing between the oxygen concentrator and the nasal cannula tubing. Interview on 02/15/24 at 2:24 P.M. with RN #297 confirmed a check mark documented on the electronic TAR indicated the order for changing oxygen tubing was completed. Further, changing oxygen tubing would include any extension tubing between the concentrator and the nasal cannula. Oxygen tubing dated 11/29/23 would suggest the tubing was not changed as indicated in the medical record for Resident #71 and Resident #74. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365101 If continuation sheet Page 16 of 16