Health inspection·December 4, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Incidents (SRI) reporting revealed as of [DATE] the facility had not initiated an SRI for the incident involving Resident #1 on [DATE]. There were no other similar incidents related to this incident in the system. Interview on [DATE] at 9:18 A.M., with Resident #1's daughter revealed the daughter attended the care conference on [DATE] with the facility and the family requested investigation about the incident on [DATE], including video footage, at the meeting. Per the Resident #1's daughter the facility denied the family's request to view the video footage stating the corporate office had to release it. Interview on [DATE] at 9:48 A.M., with Resident #1's spouse revealed the spouse was present at the time of the care conference on [DATE] with the facility staff. Per Resident #1's spouse the family requested to view the video footage and was denied by the facility. Per the spouse the facility stated the facility reported to the family the corporate office would have to release the footage for viewing. Per the resident's spouse the family alleged mistreatment of Resident #1 and demanded answers to what happened to the resident on [DATE]. Resident #1's spouse stated the family feels the facility is hiding information and details regarding the resident's death due to care not being provided. Interview on [DATE] at 2:30 P.M., with CNP #175 stated he was present for the care conference with the facility staff and Resident #1's family on [DATE]. CNP #175 stated the family requested video footage of the time Resident #1 was outside on [DATE] and the facility staff stated the video cameras may not be operational at the time of the incident, but if the cameras worked the footage would have to come from the corporate office. CNP #175 stated the family was not given a timeline in which the footage would be available for their viewing. CNP #175 stated the family repeatedly requested to see the video footage during the meeting. Interview on [DATE] at 10:00 A.M., with Administrator, Corporate Registered Nurse (RN), and ADON revealed the Corporate RN stated the video footage is only available for 3 days after the time recorded. Corporate RN stated they were still awaiting a response regarding the availability of the footage at the time of the interview. During the interviews, the Administrator and ADON were asked if the family reported any concerns, allegations of neglect, or requested to view the video footage and the Administrator, Corporate RN, and ADON all denied any reports of allegations of neglect; all staff stated the family did not request to view any video footage and there was no investigation. The ADON stated the ADON, CNP #175, and the DON were present at the care conference on [DATE] with the family. The ADON stated the DON was present via conference call on the phone due to her medical leave status. Interview on [DATE] at 10:50 A.M., with SS #500 revealed she was present at the time of the care conference on [DATE] with Resident #1's family. SS #500 presented the care conference to the surveyor and reviewed the points of care discussed with the family. SS #500 stated the family did not request to see video footage but did ask if the police had been contacted. SS #500 stated due to the family all speaking at once and asking different questions at once SS #500 was unsure if all the concerns were addressed. Interview on [DATE] at 9:48 A.M., with CNP #175 revealed the CNP no longer is employed at the facility. Per CNP #175 the last day of employment was [DATE]. CNP #175 stated during the care conference on [DATE] with the family, the family alleged mistreatment of Resident #1 by the facility night shift nurse. CNP #175 stated due to emotions of the family at the time of the meeting no facility staff were able to address their concerns. CNP #175 stated again the family continuously requested to view the video footage but was told the footage would have to be released by the corporate office. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 2 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on at [DATE] at 10:35 A.M., with local police detective (LPD) #900 revealed Resident #1's family contacted the police department and stated they felt the facility was at fault for the death of Resident #1. LPD #900 stated at the time of the interview there was still an open case to investigate. Per LPD #900 the facility had reported to the detective the cameras did not work on the outside of the facility. Review of the local newspaper article dated [DATE] and to be found at https://www.limaohio.com/top-stories/[DATE]/mans-death-at-nursing-home-is-subject-of-probe/ revealed the family of Resident #1 had reported to The Lima News that staff at the facility apparently forgot about her brother and he was left outdoors in 20-degree temperatures for a prolonged period of time. When found, lifesaving efforts were initiated and Resident #1 was taken to Memorial Health System, where he was pronounced dead. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation dated [DATE] revealed if resident abuse or neglect is suspected the suspicion must be immediately reported to the Administrator and other officials per state law. All allegations are to be thoroughly investigated and reported to the state agency within 2 hours for any allegations resulting in serious injury. This deficiency represents non-compliance for Complaints Numbers OH00148770 and OH00148780. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 3 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, local police detective interview, staff interviews, family interview, review of local newspaper article, and review of the Self-Reported Incident reporting website, the facility failed to investigate allegations of mistreatment/neglect of a resident. This affected one (#1) of six residents reviewed for potential mistreatment/neglect. The current census is 69. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed and admission date of [DATE] and discharged on [DATE]. Diagnoses for Resident #1 included: metabolic encephalopathy, diabetes type two, kidney disease, pulmonary edema, and acute respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Per the assessment the resident had not been diagnosed with any neurological disorders. Per the assessment the resident had been diagnosed with depression but no other psychiatric disorders. Review of Resident #1's care plans dated [DATE] revealed a focus for risk of injury due to smoking. Interventions include resident is his own responsible party, resident chooses to go outside and smoke independently although against policy. Educate residents on smoking schedule and policy. Resident signs himself out of facility and leaves facility. Review of Resident #1's progress notes revealed on [DATE] at 5:50 A.M., the nurse coming into the facility for her shift was walking up to the doors and found Resident #1 in his scooter in front of the door, unresponsive. The nurse checked the resident for a pulse and did not find one. The nurse called for help, brought the resident into the facility, and initiated Cardio-pulmonary resuscitation (CPR) to the resident while staff called EMS. Per the note the nurse continued CPR until emergency medical services (EMS) arrived. Review of the care conference document dated [DATE] at 9:00 A.M., revealed an in-person meeting was held with Resident #1's family, Certified Nurse Practitioner (CNP) #175, Licensed Practical Nurse (LPN) #122, Assistant Director of Nursing (ADON), Social Service (SS) #500 and MDS #600 and the Director of Nursing (DON) were present via telephone. Per the document the family expressed concerns regarding the fall in [DATE]; who was notified for resident's death; was a police report filed for resident's death; who was working on shift when resident passed; and the events leading up to death. Further review of the medical record for Resident #1 revealed no investigation into the incident on [DATE] was noted in the medical record. Review of the Electronic Information Dissemination & Collection Data system for Self-Reported Incidents (SRI) reporting revealed as of [DATE] the facility had not initiated an SRI for the incident involving Resident #1 on [DATE]. There were no other similar incidents related to this incident in the system. Interview on [DATE] at 3:05 P.M., with SS #500 revealed the social service director was unaware if the outside cameras were operational at the time of the incident with Resident #1 on [DATE]. Per SS #500, Resident #1 was able to make his own decisions and was non-compliant with the facility's policy for smoking. SS #500 stated the resident signed himself out of the facility and left on his own to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 4 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smoke by himself. SS #500 stated staff would educate the resident on the safe smoking procedures and the resident continued to sign himself out to go outside to smoke. SS #500 stated the family had been notified of the transfer to the hospital on [DATE] and the family came into the facility on [DATE] for a care conference to discuss the incident. Interview on [DATE] at 9:18 A.M., with Resident #1's daughter revealed the daughter attended the care conference on [DATE] with the facility and the family requested investigation about the incident on [DATE], including video footage, at the meeting. Per the Resident #1's daughter the facility denied the family's request to view the video footage stating the corporate office had to release it. Interview on [DATE] at 9:48 A.M., with Resident #1's spouse revealed the spouse was present at the time of the care conference on [DATE] with the facility staff. Per Resident #1's spouse the family requested to view the video footage and was denied by the facility. Per the spouse the facility stated the facility reported to the family the corporate office would have to release the footage for viewing. Per the resident's spouse the family alleged mistreatment of Resident #1 and demanded answers to what happened to the resident on [DATE]. Resident #1's spouse stated the family feels the facility is hiding information and details regarding the resident's death due to care not being provided. Interview on [DATE] at 2:30 P.M., with CNP #175 stated he was present for the care conference with the facility staff and Resident #1's family on [DATE]. CNP #175 stated the family requested video footage of the time Resident #1 was outside on [DATE] and the facility staff stated the video cameras may not be operational at the time of the incident, but if the cameras worked the footage would have to come from the corporate office. CNP #175 stated the family was not given a timeline in which the footage would be available for their viewing. CNP #175 stated the family repeatedly requested to see the video footage during the meeting. Interview on [DATE] at 10:00 A.M., with Administrator, Corporate Registered Nurse (RN), and ADON revealed the Corporate RN stated the video footage is only available for 3 days after the time recorded. Corporate RN stated they were still awaiting a response regarding the availability of the footage at the time of the interview. During the interviews, the Administrator and ADON were asked if the family reported any concerns, allegations of neglect, or requested to view the video footage and the Administrator, Corporate RN, and ADON all denied any reports of allegations of neglect; all staff stated the family did not request to view any video footage and there was no investigation. The ADON stated the ADON, CNP #175, and the DON were present at the care conference on [DATE] with the family. The ADON stated the DON was present via conference call on the phone due to her medical leave status. Interview on [DATE] at 10:50 A.M., with SS #500 revealed she was present at the time of the care conference on [DATE] with Resident #1's family. SS #500 presented the care conference to the surveyor and reviewed the points of care discussed with the family. SS #500 stated the family did not request to see video footage but did ask if the police had been contacted. SS #500 stated due to the family all speaking at once and asking different questions at once SS #500 was unsure if all the concerns were addressed. Interview on [DATE] at 3:20 P.M., with the DON revealed she did not hear any allegations of abuse from the family during the care conference, but she stated it was 'hard to hear' due to the family all speaking at once and she was present via the telephone conference call. Interview on [DATE] at 4:20 P.M., prior to the exit conference, Corporate RN #600 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 5 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility cameras did not work and stated the corporate office did not have any access to them. The Corporate RN #600 stated she spoke with the maintenance director who told her the video footage would have been erased after 3 days if the cameras did work. The Corporate RN #600 produced an email from a corporate staff member stating the corporate office did not have access to the video footage since 2021. Interview on [DATE] at 9:48 A.M., with CNP #175 revealed the CNP no longer is employed at the facility. Per CNP #175 the last day of employment was [DATE]. CNP #175 stated during the care conference on [DATE] with the family, the family alleged mistreatment of Resident #1 by the facility night shift nurse. CNP #175 stated due to emotions of the family at the time of the meeting no facility staff were able to address their concerns. CNP #175 stated again the family continuously requested to view the video footage but was told the footage would have to be released by the corporate office. Interview on at [DATE] at 10:35 A.M., with local police detective (LPD) #900 revealed Resident #1's family contacted the police department and stated they felt the facility was at fault for the death of Resident #1. LPD #900 stated at the time of the interview there was still an open case to investigate. Per LPD #900 the facility had reported to the detective the cameras did not work on the outside of the facility. Review of the local newspaper article dated [DATE] and to be found at https://www.limaohio.com/top-stories/[DATE]/mans-death-at-nursing-home-is-subject-of-probe/ revealed the family of Resident #1 had reported to The Lima News that staff at the facility apparently forgot about her brother and he was left outdoors in 20-degree temperatures for a prolonged period of time. When found, lifesaving efforts were initiated and Resident #1 was taken to Memorial Health System, where he was pronounced dead. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation dated [DATE] revealed if resident abuse or neglect is suspected the suspicion must be immediately reported to the Administrator and other officials per state law. All allegations are to be thoroughly investigated and reported to the state agency within 2 hours for any allegations resulting in serious injury. This deficiency represents non-compliance for Complaints Numbers OH00148770 and OH00148780. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 6 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview, the facility failed to ensure the medical records contained the name of the nurse who provided care and all assessments contained accurate information. This affected two (#1 and #4) residents of four resident medical records reviewed for accuracy. The current census is 69. Findings include: 1. Review of Resident #1's medical record revealed and admission date of 05/31/23 and discharged on 11/27/23. Diagnoses for Resident #1 included: metabolic encephalopathy, diabetes type two, kidney disease, pulmonary edema, and acute respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Per the assessment the resident had not been diagnosed with any neurological disorders. Per the assessment the resident had been diagnosed with depression but no other psychiatric disorders. Review of Resident #1's care plans dated 06/01/23 revealed a focus for potential for injuries of falls related to hypotension. Interventions revised on 06/03/23 included assist resident in positioning, call light within reach, check vitals each shift for hypotension issues, encourage use of call light, resident room moved closer to nurses' station for monitoring, matt next to bed (revised on 06/09/23), and move bed against wall to provide space for safe mobility. Further review of Resident #1's medical records revealed on 06/08/23 the resident's medication was administered by a nurse using the electronic signature of ag3. Review of the facility's electronic signature log revealed ag3 represented agency 300 badge. No identifying name for the nurses using the agency 300 signature was noted on the electronic signature log. Review of Resident #1's progress notes dating 11/27/23 at 7:47 A.M., revealed the note was signed electronically using agency 300 signature. Per the note the nurse document in the text Licensed Practical Nurse (LPN) #150. Review of the progress note dated 11/27/23 at 5:53 A.M., revealed the signature was agency 300, no identifying name was documented in the record. Further review of Resident #1's fall follow-up documentation dating from 06/10/23 to 06/12/23 revealed on 06/10/23 at 12:29 P.M., the resident's vital signs was documented as 06/11/23 at 9:58 A.M.: Blood Pressure (BP) 112/74, Temperature (T) 97.9, Pulse (P) 67, Respirations (R) 16, Oxygen saturation (O2) 95 on room air, and pain 7 out of 10. On 06/11/23 at 12:30 P.M., the nurse documented Resident #1's vital signs in the fall follow-up were 06/11/23 at 9:58 A.M.: BP 112/74, T 97.9, Pulse (P) 67, R 16, O2 95% on room air, and pain 7 out of 10. On 06/12/23 at 3:42 A.M., the nurse documented Resident #1's vital signs in the fall follow-up were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 7 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 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 06/11/23 9:58 A.M. BP 112/74, T 97.9, Pulse (P) 67, R 16, O2 95% on room air, and pain 7 out of 10. Level of Harm - Minimal harm or potential for actual harm On 06/12/23 at 3:07 P.M. the nurse documented Resident #1's vital signs in the fall follow-up were 06/11/23 at 9:58 A.M.: BP 112/74, T 97.9, Pulse (P) 67, R 16, O2 95% on room air, and pain 7 out of 10. Residents Affected - Few Interview on 12/04/23 at 1:33 P.M., with Director of Nursing (DON) and Assistant Director of Nursing (ADON) verified the DON had documented Resident #1's fall assessment dated [DATE] at 3:42 A.M. on the date 11/01/23 at 2:49 P.M. (a late entry) and the DON used the vital signs from 06/11/23 at 9:58 A.M. for the fall assessment. DON and ADON verified the vital signs were copied and pasted into the fall assessment and did not reflect an accurate assessment. 2. Review of Resident #4s medical record revealed an admission date of 04/25/23 and discharged [DATE]. Diagnoses for Resident #4 included: arthritis, asthma, chronic obstructive pulmonary, and pleural effusions. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Review of Resident #4's care plans dated 04/25/23 revealed a focus for risk of falls. Interventions included were appropriate for the focus. Further review of Resident #4's records revealed the resident sustained a fall on 10/22/23 at 1:21 A.M. and on 11/05/23 at 1:05 A.M. Review of the fall investigations for Resident #4 dated 10/22/23 revealed the nurse did not sign the handwritten form and the electronic form completed in the record identified the nurse as agency 600'. Review of the documentation for the fall on 11/05/23. the nurse did not sign the handwritten form and the electronic documentation identified the nurse as agency 500. Interview on 12/04/23 at 3:10 P.M., with the ADON verified the electronic signatures did not identify who the nurses were caring for Resident #4 on 10/22/23 and 11/05/23 in the fall investigation documents. Review of the daily assignment sheet dated 11/26/23 revealed for the 6:00 P.M. to 10:00 P.M. shift for 300-hall LPN #175 was scheduled. From 6:00 P.M. to 10:00 A.M., LPN #188 was scheduled for the 100-200 halls. No nurse was assigned the 300-400 halls from 10:00 P.M. to 10:00 A.M. per the daily assignment sheet. Interview on 12/04/23 at 3:10 P.M., with the DON, ADON, and Medical Records (MR) #455 verified the method the facility uses to identify the agency user logins in the electronic system consisting of the handwritten daily schedules. Per MR #455 the daily schedules were inaccurate for the agency staff present on 11/26/23 at 5:50 A.M., assigned to the 300-hall. Per ADON and MR #455 stated the only way the facility is able to identify the nurse using the agency login identifier is by the daily schedule. The ADON verified there were no licensed names or identifiers in the medical records for the agency staff contracted to work at the facility. The ADON verified the facility's policy for electronic signatures does not specify how the facility will identify the agency nurses' names in the records. Review of the policy titled, Electronic Medical Records dated March 2014, revealed the policy did not address how the facility will identify those individuals who are authorized to sign (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 8 of 9 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 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 electronically and describe the security safeguards to prevent unauthorized use of these signatures. The policy did not include how it will ensure each staff responsible for an attestation has an individualized identifier. This deficiency represents non-compliance for Complaint Number OH00148770. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365202 If continuation sheet Page 9 of 9