Inspection·December 19, 2024

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of recipes, observations, staff interviews and policy review, the facility failed to provide special dietary foods as ordered by the physician. This affected three (#14, #15 and #37) of five residents reviewed for special dietary foods. The facility census was 71. Findings include: 1. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dysphagia, weight loss history and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition and required assistance with eating. Further review of Resident #14's medical record revealed the resident had a diet order for fortified foods at each meal. 2. Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstruction pulmonary disease, nausea and history of weight loss. Review of the MDS assessment dated [DATE] revealed Resident #15 had intact cognition and required assistance with eating. Further review of Resident #15's medical record revealed the resident had a diet order for fortified foods at each meal. 3. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia, heart disease and history of weight loss. Review of the MDS assessment dated [DATE] revealed Resident #37 had severely impaired cognition and required assistance with eating. Further review of Resident #37 medical record revealed the resident had a diet order for fortified foods at each meal. Review of fortified foods recipe for fortified oatmeal included sugar, butter, dry milk and evaporated milk. The fortified potato recipe revealed use of half and half cream and butter. Observation on 12/17/24 at 12:24 P.M. of Resident #14, #15, and #37 had served ravioli, green beans, bread and sherbert. There were no fortified foods served at the lunch meal. Interview on 12/17/24 at 11:18 A.M. the [NAME] #250 revealed she did not follow fortified food recipes, including oatmeal and potatoes for Resident #14, #15 and #37. [NAME] #250 stated the recipes included more ingredients to increase the calories in the foods. [NAME] #250 verified she had not prepared any fortified foods for the lunch meal Interview on 12/18/24 at 1:14 P.M. the Dietary Manager, (DM) #280 revealed the cooks have not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 2 of 6 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 0800 Level of Harm - Minimal harm or potential for actual harm prepared fortified foods by following the by fortified food recipes, which included high caloric ingredients. The fortified foods are planned for the residents as assessed by the Registered Dietitian, (RD) #140. Review of the facility policy tilted, Diet Orders Policy dated 03/18/24 revealed the facility will ensure residents are provided meals as ordered by their healthcare provider. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 3 of 6 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interview, the facility failed to store foods and maintain kitchen equipment under sanitary conditions. This affected all 71 residents who received food from the kitchen. The facility census was 71. Findings include: During initial kitchen tour on 12/16/24 at 8:47 A.M., the was a large unlabeled and undated food bin containing a white substance under the food preparation counter. There was soy sauce, Worcestershire sauce, mayonnaise and opened bag of cheese with no expiration date or use by date in the walk-in refrigerator. Further observations of the stove ventilation revealed the hood had brown fuzzy debris of a quarter of inch in length hanging from the bottom rack. The debris was over the cooking surface of the stove, which contained open pans of cooking food. Interview on 12/016/24 at 8:50 A.M. the Dietary Manager, (DM) #280 verified there was no use by dates for open foods of soy sauce, Worcestershire sauce, mayonnaise and bag of cheese. DM #280 verified the stove hood was dirty and there was no evidence of stove hood cleaning provided. DM #280 stated there were no facility policies for labeling, and storage of foods and there was no facility policies provided of equipment cleaning. The facility confirmed all 71 residents receive their meals from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 4 of 6 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of a memo from Centers for Medicare and Medicaid Services (CMS), the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when a resident with a chronic diabetic ulcer requiring wound treatments and dressing changes was not timely placed on enhance barrier precautions. This affected one (#60) of two reviewed for infection control. The facility census was 71. Residents Affected - Few Findings include: Record review of Resident #60 revealed an admission date of 02/03/24. Diagnoses include type two diabetes mellitus with foot ulcer 02/03/24, viral hepatitis B, iron deficiency anemia, vitamin d deficiency, chronic pain syndrome, pleural effusion, fibromyalgia, cirrhosis of the liver, major depressive disorder, encephalopathy, chronic obstructive pulmonary disease, hypertension, benign prostatic hyperplasia, nausea, and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact and has a Diabetic foot ulcer. Review of Resident #60's wound clinic report dated 10/07/24 revealed the right medial forefoot abrasion went from abrasion to diabetic ulcer per Wound Certified Nurse Practitioner. Review of Resident #60's physician order dated 10/14/24 revealed an order to cleanse wound to right ball of foot with normal saline apply calcium alginate with silver to wound bed then zinc to peri wound then cover with abdominal pad and kerlix secure with tape for diabetic ulcer once a day. This order was discontinued 11/18/24. Review of Resident #60's physician order dated 11/18/24 revealed an order to cleanse wound to right ball of foot with normal saline apply santyl to wound bed then cover with calcium alginate with silver then zinc to peri wound then cover with abdominal pad and kerlix secure with tape for diabetic ulcer. This order was discontinued on 12/04/24. Review of Resident #60's physician order dated 12/04/24 revealed an order to cleanse wound to right ball of foot with normal saline apply santyl to wound bed then cover with abdominal pad and kerlix secure with tape. change daily and as needed for diabetic ulcer once a day. This order was discontinued on 12/18/24. Observation on 12/16/24 at 3:55 P.M. revealed there was no sign by the room or information showing Resident #60 was on enhanced barrier precautions. Review of a Physician Order dated 12/16/24 revealed Enhanced barrier precautions related to diabetic wound. Further review of the medical record on 12/17/24 revealed Resident #60 had an abrasion to the right medial forefoot on 08/01/24 that was classified as a chronic diabetic ulcer on 10/07/24. The wound required treatments and dressing changes and was not placed on enhanced barrier precautions until 12/16/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365586 If continuation sheet Page 5 of 6 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 365586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Creek Nursing Center 141 Spruce Lane West Union, OH 45693 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Director of Nursing (DON) on 12/19/24 at 1:34 P.M. verified Resident #60 has a chronic diabetic foot ulcer and was not placed on enhanced barrier precautions until 12/16/24. Review of memo from CMS titled QSO-24-08-NH dated 03/20/24 revealed enhanced barrier precautions are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO). Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Event ID: Facility ID: 365586 If continuation sheet Page 6 of 6