Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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** Based on
medical record review, observation, and resident and staff interview, the facility failed to accommodate the
known preferences for a resident. This affected one individual (#13) of 15 residents interviewed during the
survey regarding accommodation of needs. The facility census was 44.
Residents Affected - Few
Findings include:
Resident #13 was admitted to the facility on [DATE] with diagnoses including bilateral above the knee
amputations, non pressure ulcer of the above the knee stumps, muscle weakness, anxiety, and depression.
Review of the minimum data set (MDS) assessment revealed the resident scored a 15 on the Brief
Interview for Mental Status (BIMS) indicating he has no cognitive deficits . He exhibited no behaviors. He
requires extensive assistance with bed mobility and transfers. He requires physical help of one person in
part of the bathing activity. He propels a manual wheelchair on his own on and off the unit .
Review of the plan for care, dated 10/15/19 revealed the resident has an activity of daily living (ADL) self
care deficit related to recent hospital stay for sepsis, bilateral above knee amputations, decreased self
mobility, generalized muscle weakness, mood/behavior concerns, age, medications taken, non-compliance
with prescribed care regimen, verbally aggressive at times.
The goal indicated the resident will be clean, dressed and well groomed daily to promote dignity and
psychosocial well-being. The interventions included the resident will receive assistance necessary to meet
ADL needs, staff will assist to bathe/shower the resident as needed, therapy is to evaluate and treat the
resident per physician orders.
On 12/02/19 at 9:30 A.M. Resident #13 stated the shower/tub transfer bench in therapy is broken and has
been broken for several weeks. He stated he can't practice his shower transfers without a tub/shower
bench. He stated he wants to use the transfer bench in the shower room and take a shower like a regular
person. He stated he does not want to use the shower chair with a hole in it.
On 12/02/19 at 10:00 A.M. observation of the tub /shower bench in the therapy room revealed an area on
the seat where a screw with breaking though causing a raised rough surface.
Interview with Occupational Therapy Assistant (OTA) #400 on 12/02/19 at 10:00 A.M. verified the
tub/shower bench had a rough surface and was not able to be used. She stated she had told the
Administrator last week and the Administrator told her she was ordering a new shower bench for therapy.
She
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
365600
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
stated Resident #13 did not currently have a place to live so they were not worried about his ability to use a
transfer bench. When asked if the resident could have a transfer bench to take a shower in the shower room
of the facility she responded by stating there are shower chairs that he could use because he does not slide
transfer and is capable to transfer into a shower chair. She verified that the facility and therapy staff were
aware of Resident #13 preference to use a shower bench due to his age and bilateral above the knee
amputations but did not fell it was necessary for the resident's care at this time.
Interview with Resident #13 on 12/03/19 at 3:00 P.M. he stated on the transitional care unit where he is
currently residing there is a refrigerator freezer used for the storage of the resident's food they bring into the
facility. He stated he had went to Walmart with activities and bought frozen burritos to have as a snack for
when his friend came to visit. The facility placed them in the refrigerator/freezer used for the resident's food.
The refrigerator and freezer has a pad lock on the doors. He stated the resident have to have staff unlock
the the refrigerator and freezer when he wanted his food. He stated he is capable of getting his food
independently but due to the locks he has to ask staff to unlock the refrigerator/freezer and assist him.
Interview with the Administrator on 12/03/19 at 3:30 P.M. she verified the refrigerator/freezer located on the
transitional care unit was for the residents to store their personal food in that was brought into the facility.
She stated one of the former resident's were eating other peoples food so they locked the refrigerator and
freezer to prevent that from happening.
Interview with OTA #400 on 12/05/19 at 12:00 P.M. she verified the refrigerator and freezer located in the
kitchenette on the transitional care unit was used to store the food that resident's brought into the facility.
She stated initially the refrigerator was not locked until one of the former resident's got into the refrigerator
and ate other resident's food. She verified the former resident was expired/no longer resides in the facility.
Interview with State Tested Nursing Assistant (STNA) #210 on 12/05/19 at 12:20 P.M. verified the
refrigerator and freezer located in the kitchenette on the transitional care unit was used to store the food
that resident's brought into the facility. She stated initially the refrigerator was not locked until one of the
former resident's got into the refrigerator and ate other resident's food. She verified the former resident was
expired/no longer resides in the facility. She stated there was usually one STNA on the transitional care
hallway and if the resident's requested any food from the refrigerated they may have to wait until the STNA
was available to unlock the refrigerator.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 2 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and resident and staff interview, the facility failed to ensure the environment was free from
pervasive odors. This affected three (#188, #30, and #13) out of seven residents reviewed. This had the
potential to affect 18 (#29, #26, #12, #193, #36, #31, #9, #20, #188, #25, #24, #7, #18, #8, #4, #37, #23
and #32) residents who reside on the 400 hall unit. The current census is 44.
Findings include:
Observation on 12/02/19 at 8:00 A.M. revealed a strong pervasive odor was noted beginning at the front
entrance of the hall to the middle of the hall. The pervasive odor persisted throughout the survey to the exit
dated of 12/05/19.
Interview on 12/02/19 at 3:10 P.M. with Resident #188 revealed the resident was uncomfortable with the
pervasive odor in the resident's hall. Per the resident the smell is constant with no relief. Resident #188
stated the pervasive odor has been in the facility for an extended time and the resident has complained to
nurses, housekeepers, and the Administrator with no relief from the odor.
Observation of the 400 hallway on 12/02/19 at 9:00 A.M. revealed a very strong pervasive odor near the
soiled utility room extending back just beyond room [ROOM NUMBER].
Interview on 12/02/19 at 10:00 A.M. with Resident #13 he stated he has made a couple of friends who lives
on the 400 hallway. He stated the 400 hallway smells of a strong urine odor. He stated he has been in the
facility for two months and it has always smelled of strong urine.
Observation on 12/02/19 at 11:30 A.M. revealed the pervasive odor was present on the 400 hallway.
Interview on 12/02/19 at 4:30 P.M. with the Administrator and the Director of Nursing (DON) verified the
facility staff are aware of the pervasive odor at the start of the 400 hall. Per the Administrator the pervasive
odor is emanating from the soiled linen storage room located in between the beauty shop and the resident's
rooms on the 400 hall.
On 12/03/19 at 8:15 A.M. the pervasive odor remained in the 400 hallway.
On 12/04/19 at 8:30 A.M. the pervasive odor remained in the 400 hallway.
Interview on 12/03/19 at 9:19 AM with Resident #30 stated the entrance to the 400 hallway has a bad smell
to it.
Interview on 12/04/19 at 4:00 P.M. interview with the Maintenance Director #420 stated there has bee a
pervasive odor coming from Resident #12 and #18's room for weeks. Observation of Resident #12 and
#18's room revealed the floor covering was very worn. The smell did become stronger when approaching
the resident in the second bed. The resident was sitting in a fabric chair. The facility confirmed this had the
potential to affect 18 (#29, #26, #12, #193, #36, #31, #9, #20, #188, #25, #24, #7, #18, #8, #4, #37, #23
and #32) residents who reside on the 400 hall unit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 3 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of facility self-reported incidents (SRI's), review of personal files, staff
interview, and policy review, the facility failed to ensure residents were free from misappropriation of
medications. This affected seven residents, (#25, #29, #37, #189, #190, #191, #192), out of 13 residents
reviewed for medications. The current census is 44.
Residents Affected - Some
Findings include:
1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #25 include cerebral palsy, osteoarthritis, polyarthritis, and weakness.
Review of Resident #25's comprehensive minimum data set, (MDS) dated [DATE] revealed the resident has
intact cognition.
Review of a facility SRI dated 11/19/19 revealed on 11/18/19 a nurse reported to the Administrator the
departing nurse from the previous shift had reported Resident #25 had received an as needed pain
medication in the morning. Per the report Resident #25 denied receiving the pain medication when the
reporting nurse asked the resident about pain. Per the SRI report, Resident #25 consented to a drug test
which was negative for the prescribed pain medication or any other controlled substance. Per the SRI the
facility's investigation of the allegation was unsubstantiated as the evidence was inconclusive.
Further review of the medications for Resident #25 revealed on 10/15/19 the resident was prescribed to
receive Hydrocodone 5/325 milligrams, (mg), every four hours as needed for pain.
According to Resident #25's controlled drug record revealed Registered Nurse, (RN) #300 signed out one
Hydrocodone tablet on 11/18/19 at 5:15 A.M.
Review of Resident #25's Medication Administration Record, (MAR), dated 11/18/19 revealed the resident
was administered a Hydrocodone tablet by RN #300.
Review of Resident #25's laboratory results revealed on 11/19/19 the resident's drug test results was
negative for Hydrocodone.
Interview on 12/02/19 at 9:00 A.M. with Resident #25 revealed the resident recalled being interviewed
about missing medications but stated she did not have any pain and did not receive any as needed pain
medications recently.
Interview on 12/04/19 at 2:00 P.M. with the Director of Nursing (DON) revealed all medications for Resident
#25 were reviewed after the allegation of misappropriation was reported on 11/18/19. The DON verified
when she interviewed Resident #25 the resident claimed she had not taken any of her pain medications.
The DON verified the resident agreed to a drug test and the results of the test for the pain medication were
negative.
Interview on 12/05/19 at 11:20 A.M. with the Administrator and the DON revealed on 11/18/19 after
Licensed Practical Nurse, (LPN) #500 reported to the DON the allegation of misappropriation of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 4 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
medications for Resident #25 the DON and Administrator conducted an investigation into the allegation. Per
the Administrator the investigation did show missing medications for Resident #25 and other residents. The
Administrator stated another SRI dated 11/22/19 was initiated and further medications were discovered to
be missing. Per the Administrator all missing medications were signed out by RN #300.
Review of the SRI dated 11/22/19 revealed missing narcotic count sheets and medications were discovered
by the Administrator and DON during the investigation. Per the SRI, RN #300 was identified as the staff
responsible for the missing medications.
2. Review of Resident #29's medical record revealed the resident was admitted to the facility on diagnoses
for Resident #29 include obesity, retention of urine, chronic kidney disease, and epilepsy.
Review of Resident #29's prescribed medications revealed on 10/04/19 the resident was prescribed to
receive Hydrocodone 5/325 mg one tablet every four hours as needed for pain.
Review of Resident #29's narcotic count sheets revealed on 11/13/19 RN #300 signed for a new narcotic
card for Hydrocodone 5/325 mg.
Review of the facility's SRI investigation revealed on 11/13/19 Resident #29 had three Hydrocodone tablets
not accounted for on the MAR compared to the narcotic count sheet and card dated 10/28/19.
3. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #37 include heart disease, chronic obstructive pulmonary disease, pneumonia, and
arthritis.
Review of Resident #37's prescribed medications revealed on 09/03/19 the resident was prescribed to
receive Hydrocodone 5/325 mg one tablet every four hours as needed for pain.
Review of the facility's SRI investigation revealed from 09/27/19 to 10/10/19 there were 13 Hydrocodone
tablets missing from the MAR dated 10/2019 compared to the narcotic count sheets for Resident #37.
4. Review of Resident #189's medical record revealed the resident was admitted to the facility on [DATE]
and discharged on 11/15/19. Diagnoses for Resident #189 include heart disease, pain in knees,
hypertension, anemia, and diabetes.
Review of Resident #189's prescribed medications revealed on 11/01/19 the resident was prescribed to
receive Oxycodone 5/325 mg one tablet every four hours as needed for pain.
Review of the facility's SRI investigation revealed the from 10/22/19 to 11/03/19 there were three missing
Oxycodone tablets missing from the MARs dated 10/2019 to 11/2019 compared to the narcotic count
sheets for Resident #189.
5. Review of Resident #190's medical record revealed the resident was admitted to the facility on [DATE]
and discharged on 11/15/19. Diagnoses for Resident #190 include heart disease, diabetes, hypertension,
and seizures.
Review of Resident #190's prescribed medications revealed on 10/07/19 the resident was prescribed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 5 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0602
to receive Oxycodone 5/325 mg one tablet four times a day for pain.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's SRI investigation revealed RN #300 signed out another narcotic card with
documenting the card was emptied. Per the resident's MAR the narcotic count did not match the amount of
Oxycodone administered to Resident #190.
Residents Affected - Some
6. Record review of Resident #191 revealed the resident was admitted to the facility on [DATE] and
discharged on 10/22/19. Diagnoses for Resident #191 include malignant neoplasm of colon and liver,
dysphagia, pain, and weakness.
Review of Resident #191's physician orders revealed on 07/27/19 the resident was ordered to receive
Oxycodone 5/325 mg every four hours as needed for pain.
Review of the facility's investigation into Resident #191's medical record revealed the resident's narcotic
control record and narcotic pill card did not match. Per the investigation, 13 Oxycodone tablets were
missing.
7. Record review for Resident #192 revealed the resident was admitted to the facility on [DATE] and
discharged on 09/13/19. Diagnoses for Resident #192 include surgical care of digestive system, dysphagia,
seizures, and falls.
Review of Resident #192's physician orders revealed on 08/27/19 the resident was ordered to receive
Oxycodone-Acetaminophen 5/325 mg every four hours as needed for pain.
Review of the facility's investigation into Resident #192's record revealed there was one Oxycodone tablet
missing from the resident's narcotic control record and narcotic pill card.
Review of RN #300's employee file revealed the nurse was hired at the facility on 02/09/19. The nurse
signed the abuse policy on 02/09/19. Review of the disciplinary document in the employee's file revealed
the nurse was discharged from employment on 11/19/19.
Interview on 12/05/19 at 11:20 A.M. with the Administrator and the DON revealed on 11/22/19 the
Administrator initiated another SRI and investigation into all the resident's narcotic count sheet and MARs
dated from 09/2019. Per the Administrator the investigation was continuing due to RN #300's employment
started on 02/09/19. The Administrator verified there was a total of 43 missing medications from seven
(#25, #29, #27, #189, #190, #191 and #192) residents discovered during the facility's investigation. The
DON and Administrator verified RN #300 was the nurse responsible for all the missing medications. The
Administrator verified RN #300 was hired in 02/2019 and the DON and Administrator started to investigate
the missing medications from 09/2019 to 11/2019. The Administrator stated due to time constraints the
full/thorough investigation had not been completed at the time of the survey.
Review of the undated facility policy titled, 'Abuse', revealed the resident's have the right to be free from
misappropriation. Per the policy the facility will prevent all misappropriation of resident's property.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 6 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of facility self-reported incidents (SRI's), review of personal files, staff
interview, and policy review, the facility failed to implement their abuse policy to ensure residents were free
from misappropriation of medications and to ensure misappropriation of medications was thoroughly
investigated. This affected seven residents, (#25, #29, #37, #189, #190, #191, #192), out of 13 residents
reviewed for medications. The current census is 44.
Residents Affected - Some
Findings include:
1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #25 include cerebral palsy, osteoarthritis, polyarthritis, and weakness.
Review of Resident #25's comprehensive minimum data set, (MDS) dated [DATE] revealed the resident has
intact cognition.
Review of a facility SRI dated 11/19/19 revealed on 11/18/19 a nurse reported to the Administrator the
departing nurse from the previous shift had reported Resident #25 had received an as needed pain
medication in the morning. Per the report Resident #25 denied receiving the pain medication when the
reporting nurse asked the resident about pain. Per the SRI report, Resident #25 consented to a drug test
which was negative for the prescribed pain medication or any other controlled substance. Per the SRI the
facility's investigation of the allegation was unsubstantiated as the evidence was inconclusive.
Further review of the medications for Resident #25 revealed on 10/15/19 the resident was prescribed to
receive Hydrocodone 5/325 milligrams, (mg), every four hours as needed for pain.
According to Resident #25's controlled drug record revealed Registered Nurse, (RN) #300 signed out one
Hydrocodone tablet on 11/18/19 at 5:15 A.M.
Review of Resident #25's Medication Administration Record, (MAR), dated 11/18/19 revealed the resident
was administered a Hydrocodone tablet by RN #300.
Review of Resident #25's laboratory results revealed on 11/19/19 the resident's drug test results was
negative for Hydrocodone.
Interview on 12/02/19 at 9:00 A.M. with Resident #25 revealed the resident recalled being interviewed
about missing medications but stated she did not have any pain and did not receive any as needed pain
medications recently.
Interview on 12/04/19 at 2:00 P.M. with the Director of Nursing (DON) revealed all medications for Resident
#25 were reviewed after the allegation of misappropriation was reported on 11/18/19. The DON verified
when she interviewed Resident #25 the resident claimed she had not taken any of her pain medications.
The DON verified the resident agreed to a drug test and the results of the test for the pain medication were
negative.
Interview on 12/05/19 at 11:20 A.M. with the Administrator and the DON revealed on 11/18/19 after
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 7 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0607
Level of Harm - Minimal harm
or potential for actual harm
Licensed Practical Nurse, (LPN) #500 reported to the DON the allegation of misappropriation of
medications for Resident #25 the DON and Administrator conducted an investigation into the allegation. Per
the Administrator the investigation did show missing medications for Resident #25 and other residents. The
Administrator stated another SRI dated 11/22/19 was initiated and further medications were discovered to
be missing. Per the Administrator all missing medications were signed out by RN #300.
Residents Affected - Some
Review of the SRI dated 11/22/19 revealed missing narcotic count sheets and medications were discovered
by the Administrator and DON during the investigation. Per the SRI, RN #300 was identified as the staff
responsible for the missing medications.
2. Review of Resident #29's medical record revealed the resident was admitted to the facility on diagnoses
for Resident #29 include obesity, retention of urine, chronic kidney disease, and epilepsy.
Review of Resident #29's prescribed medications revealed on 10/04/19 the resident was prescribed to
receive Hydrocodone 5/325 mg one tablet every four hours as needed for pain.
Review of Resident #29's narcotic count sheets revealed on 11/13/19 RN #300 signed for a new narcotic
card for Hydrocodone 5/325 mg.
Review of the facility's SRI investigation revealed on 11/13/19 Resident #29 had three Hydrocodone tablets
not accounted for on the MAR compared to the narcotic count sheet and card dated 10/28/19.
3. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #37 include heart disease, chronic obstructive pulmonary disease, pneumonia, and
arthritis.
Review of Resident #37's prescribed medications revealed on 09/03/19 the resident was prescribed to
receive Hydrocodone 5/325 mg one tablet every four hours as needed for pain.
Review of the facility's SRI investigation revealed from 09/27/19 to 10/10/19 there were 13 Hydrocodone
tablets missing from the MAR dated 10/2019 compared to the narcotic count sheets for Resident #37.
4. Review of Resident #189's medical record revealed the resident was admitted to the facility on [DATE]
and discharged on 11/15/19. Diagnoses for Resident #189 include heart disease, pain in knees,
hypertension, anemia, and diabetes.
Review of Resident #189's prescribed medications revealed on 11/01/19 the resident was prescribed to
receive Oxycodone 5/325 mg one tablet every four hours as needed for pain.
Review of the facility's SRI investigation revealed the from 10/22/19 to 11/03/19 there were three missing
Oxycodone tablets missing from the MARs dated 10/2019 to 11/2019 compared to the narcotic count
sheets for Resident #189.
5. Review of Resident #190's medical record revealed the resident was admitted to the facility on [DATE]
and discharged on 11/15/19. Diagnoses for Resident #190 include heart disease, diabetes, hypertension,
and seizures.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 8 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident #190's prescribed medications revealed on 10/07/19 the resident was prescribed to
receive Oxycodone 5/325 mg one tablet four times a day for pain.
Review of the facility's SRI investigation revealed RN #300 signed out another narcotic card with
documenting the card was emptied. Per the resident's MAR the narcotic count did not match the amount of
Oxycodone administered to Resident #190.
6. Record review of Resident #191 revealed the resident was admitted to the facility on [DATE] and
discharged on 10/22/19. Diagnoses for Resident #191 include malignant neoplasm of colon and liver,
dysphagia, pain, and weakness.
Review of Resident #191's physician orders revealed on 07/27/19 the resident was ordered to receive
Oxycodone 5/325 mg every four hours as needed for pain.
Review of the facility's investigation into Resident #191's medical record revealed the resident's narcotic
control record and narcotic pill card did not match. Per the investigation, 13 Oxycodone tablets were
missing.
7. Record review for Resident #192 revealed the resident was admitted to the facility on [DATE] and
discharged on 09/13/19. Diagnoses for Resident #192 include surgical care of digestive system, dysphagia,
seizures, and falls.
Review of Resident #192's physician orders revealed on 08/27/19 the resident was ordered to receive
Oxycodone-Acetaminophen 5/325 mg every four hours as needed for pain.
Review of the facility's investigation into Resident #192's record revealed there was one Oxycodone tablet
missing from the resident's narcotic control record and narcotic pill card.
Review of RN #300's employee file revealed the nurse was hired at the facility on 02/09/19. The nurse
signed the abuse policy on 02/09/19. Review of the disciplinary document in the employee's file revealed
the nurse was discharged from employment on 11/19/19.
Interview on 12/05/19 at 11:20 A.M. with the Administrator and the DON revealed on 11/22/19 the
Administrator initiated another SRI and investigation into all the resident's narcotic count sheet and MARs
dated from 09/2019. Per the Administrator the investigation was continuing due to RN #300's employment
started on 02/09/19. The Administrator verified there was a total of 43 missing medications from seven
(#25, #29, #27, #189, #190, #191 and #192) residents discovered during the facility's investigation. The
DON and Administrator verified RN #300 was the nurse responsible for all the missing medications. The
Administrator verified RN #300 was hired in 02/2019 and the DON and Administrator started to investigate
the missing medications from 09/2019 to 11/2019. The Administrator stated due to time constraints the
full/thorough investigation had not been completed at the time of the survey.
Review of the undated facility policy titled, 'Abuse', revealed the resident's have the right to be free from
misappropriation. Per the policy the facility will prevent all misappropriation of resident's property. Per the
policy the facility Administrator will conduct a full investigation into allegations of abuse.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 9 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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, review of facility self-reported incidents (SRI's), review of personal files, staff
interview, and policy review, the facility failed to ensure misappropriation of medications was thoroughly
investigated. This affected seven residents, (#25, #29, #37, #189, #190, #191, #192), out of 13 residents
reviewed for medications. The current census is 44.
Residents Affected - Some
Findings include:
1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #25 include cerebral palsy, osteoarthritis, polyarthritis, and weakness.
Review of Resident #25's comprehensive minimum data set, (MDS) dated [DATE] revealed the resident has
intact cognition.
Review of a facility SRI dated 11/19/19 revealed on 11/18/19 a nurse reported to the Administrator the
departing nurse from the previous shift had reported Resident #25 had received an as needed pain
medication in the morning. Per the report Resident #25 denied receiving the pain medication when the
reporting nurse asked the resident about pain. Per the SRI report, Resident #25 consented to a drug test
which was negative for the prescribed pain medication or any other controlled substance. Per the SRI the
facility's investigation of the allegation was unsubstantiated as the evidence was inconclusive.
Further review of the medications for Resident #25 revealed on 10/15/19 the resident was prescribed to
receive Hydrocodone 5/325 milligrams, (mg), every four hours as needed for pain.
According to Resident #25's controlled drug record revealed Registered Nurse, (RN) #300 signed out one
Hydrocodone tablet on 11/18/19 at 5:15 A.M.
Review of Resident #25's Medication Administration Record, (MAR), dated 11/18/19 revealed the resident
was administered a Hydrocodone tablet by RN #300.
Review of Resident #25's laboratory results revealed on 11/19/19 the resident's drug test results was
negative for Hydrocodone.
Interview on 12/02/19 at 9:00 A.M. with Resident #25 revealed the resident recalled being interviewed
about missing medications but stated she did not have any pain and did not receive any as needed pain
medications recently.
Interview on 12/04/19 at 2:00 P.M. with the Director of Nursing (DON) revealed all medications for Resident
#25 were reviewed after the allegation of misappropriation was reported on 11/18/19. The DON verified
when she interviewed Resident #25 the resident claimed she had not taken any of her pain medications.
The DON verified the resident agreed to a drug test and the results of the test for the pain medication were
negative.
Interview on 12/05/19 at 11:20 A.M. with the Administrator and the DON revealed on 11/18/19 after
Licensed Practical Nurse, (LPN) #500 reported to the DON the allegation of misappropriation of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 10 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 - Some
medications for Resident #25 the DON and Administrator conducted an investigation into the allegation. Per
the Administrator the investigation did show missing medications for Resident #25 and other residents. The
Administrator stated another SRI dated 11/22/19 was initiated and further medications were discovered to
be missing. Per the Administrator all missing medications were signed out by RN #300.
Review of the SRI dated 11/22/19 revealed missing narcotic count sheets and medications were discovered
by the Administrator and DON during the investigation. Per the SRI, RN #300 was identified as the staff
responsible for the missing medications.
2. Review of Resident #29's medical record revealed the resident was admitted to the facility on diagnoses
for Resident #29 include obesity, retention of urine, chronic kidney disease, and epilepsy.
Review of Resident #29's prescribed medications revealed on 10/04/19 the resident was prescribed to
receive Hydrocodone 5/325 mg one tablet every four hours as needed for pain.
Review of Resident #29's narcotic count sheets revealed on 11/13/19 RN #300 signed for a new narcotic
card for Hydrocodone 5/325 mg.
Review of the facility's SRI investigation revealed on 11/13/19 Resident #29 had three Hydrocodone tablets
not accounted for on the MAR compared to the narcotic count sheet and card dated 10/28/19.
3. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #37 include heart disease, chronic obstructive pulmonary disease, pneumonia, and
arthritis.
Review of Resident #37's prescribed medications revealed on 09/03/19 the resident was prescribed to
receive Hydrocodone 5/325 mg one tablet every four hours as needed for pain.
Review of the facility's SRI investigation revealed from 09/27/19 to 10/10/19 there were 13 Hydrocodone
tablets missing from the MAR dated 10/2019 compared to the narcotic count sheets for Resident #37.
4. Review of Resident #189's medical record revealed the resident was admitted to the facility on [DATE]
and discharged on 11/15/19. Diagnoses for Resident #189 include heart disease, pain in knees,
hypertension, anemia, and diabetes.
Review of Resident #189's prescribed medications revealed on 11/01/19 the resident was prescribed to
receive Oxycodone 5/325 mg one tablet every four hours as needed for pain.
Review of the facility's SRI investigation revealed the from 10/22/19 to 11/03/19 there were three missing
Oxycodone tablets missing from the MARs dated 10/2019 to 11/2019 compared to the narcotic count
sheets for Resident #189.
5. Review of Resident #190's medical record revealed the resident was admitted to the facility on [DATE]
and discharged on 11/15/19. Diagnoses for Resident #190 include heart disease, diabetes, hypertension,
and seizures.
Review of Resident #190's prescribed medications revealed on 10/07/19 the resident was prescribed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 11 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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
to receive Oxycodone 5/325 mg one tablet four times a day for pain.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's SRI investigation revealed RN #300 signed out another narcotic card with
documenting the card was emptied. Per the resident's MAR the narcotic count did not match the amount of
Oxycodone administered to Resident #190.
Residents Affected - Some
6. Record review of Resident #191 revealed the resident was admitted to the facility on [DATE] and
discharged on 10/22/19. Diagnoses for Resident #191 include malignant neoplasm of colon and liver,
dysphagia, pain, and weakness.
Review of Resident #191's physician orders revealed on 07/27/19 the resident was ordered to receive
Oxycodone 5/325 mg every four hours as needed for pain.
Review of the facility's investigation into Resident #191's medical record revealed the resident's narcotic
control record and narcotic pill card did not match. Per the investigation, 13 Oxycodone tablets were
missing.
7. Record review for Resident #192 revealed the resident was admitted to the facility on [DATE] and
discharged on 09/13/19. Diagnoses for Resident #192 include surgical care of digestive system, dysphagia,
seizures, and falls.
Review of Resident #192's physician orders revealed on 08/27/19 the resident was ordered to receive
Oxycodone-Acetaminophen 5/325 mg every four hours as needed for pain.
Review of the facility's investigation into Resident #192's record revealed there was one Oxycodone tablet
missing from the resident's narcotic control record and narcotic pill card.
Review of RN #300's employee file revealed the nurse was hired at the facility on 02/09/19. The nurse
signed the abuse policy on 02/09/19. Review of the disciplinary document in the employee's file revealed
the nurse was discharged from employment on 11/19/19.
Interview on 12/05/19 at 11:20 A.M. with the Administrator and the DON revealed on 11/22/19 the
Administrator initiated another SRI and investigation into all the resident's narcotic count sheet and MARs
dated from 09/2019. Per the Administrator the investigation was continuing due to RN #300's employment
started on 02/09/19. The Administrator verified there was a total of 43 missing medications from seven
(#25, #29, #27, #189, #190, #191 and #192) residents discovered during the facility's investigation. The
DON and Administrator verified RN #300 was the nurse responsible for all the missing medications. The
Administrator verified RN #300 was hired in 02/2019 and the DON and Administrator started to investigate
the missing medications from 09/2019 to 11/2019. The Administrator stated due to time constraints the
full/thorough investigation had not been completed at the time of the survey.
Review of the undated facility policy titled, 'Abuse', revealed the resident's have the right to be free from
misappropriation. Per the policy the facility will prevent all misappropriation of resident's property. Per the
policy the facility Administrator will conduct a full investigation into allegations of abuse.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 12 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review and family and and staff interview the facility failed to ensure residents
had there assistive devices, glasses, to maintain their highest abilities at all times. This affected one (#7)
out of three residents reviewed for assistive devices. The current census is 44.
Residents Affected - Few
Findings include:
Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses for Resident #7 include heart disease, dementia, overactive bladder, and altered mental status.
Review of the minimum data set (MDS) comprehensive assessment dated [DATE] revealed the resident
has impaired cognition and does have corrective lens for vision.
Review of the electronic medical record for Resident #7 included a picture of the resident, in the picture the
resident was wearing glasses.
Review of Resident #7's care plans dated 10/05/16 revealed a focus for impaired vision. Per the care the
resident received a new pair of glasses on 10/06/16. Interventions for the focus include the resident is to
wear her glasses at all times.
Interview on 12/03/19 at 10:00 A.M. with Resident #7's family representative revealed the family have
reported to the facility Resident #7 has lost her glasses at the facility awhile ago, unable to recall exact date
but stated felt like two to three months. Per the representative there has been no response from the facility
to the family to notify them if the glasses have been searched for or found. Per the family representative,
Resident #7 was admitted with glasses and needs the glasses to read the newspaper which is the
resident's preferred activity.
Observation on 12/05/19 at 8:02 A.M. of Resident #7 revealed the resident was sitting in her wheelchair in
the main lounge of the facility. Resident #7 was observed with no glasses on. Resident #7 was observed
calm with a newspaper located on the table within reach. It did not appear Resident #7 was reading the
newspaper during the observation.
Interview on 12/05/19 at 12:03 P.M. with the Business Office Manager, (BOM), revealed the BOM had no
knowledge if Resident #7 wore glasses. Per the BOM she has never observed the resident with glasses.
The BOM verified Resident #7 was not wearing glasses during the observation on 12/05/19.
Interview on 12/05/19 at 1:10 P.M. with MDS Nurse #100 revealed after searching for Resident #7's glasses
in the resident room and around the facility the resident's glasses were located in the social services office
in the desk. Per MDS Nurse #100 there was no knowledge of how long the glasses were in the social
service office or when the glasses were reported missing. Per MDS Nurse #100 the social worker was
unable to be interviewed due to illness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 13 of 14
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
365600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lost Creek Rehabilitation and Nursing Center
804 South Mumaugh Road
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 0807
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides drinks consistent with resident needs and
preferences and sufficient to maintain resident hydration.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation and staff and resident interview, the facility failed to provide ice water to
a resident per request. This affected one (#188) out of seven residents reviewed for choices. The current
census is 44.
Findings include:
Record review of Resident #188 revealed the resident was admitted to the facility on [DATE]. Diagnoses for
Resident #188 include fusion of spine, disorder of the muscles, convulsions, seizures, depression, anxiety,
asthma, hypertension, and syncope and collapse.
Review of the Minimum Data Set, (MDS), comprehensive assessment dated [DATE] revealed Resident
#188 had intact cognition.
Interview on 12/02/19 at 3:10 P.M. with Resident #188 revealed due to the broken ice machine in the dining
room the second shift staff are not able to provide resident's fresh ice water during the dinner meal
preparation. Resident #188 stated the aides are not allowed to enter the kitchen and get ice out of the only
machine that is working. Resident #188 stated the ice machine in the dining room has been broken for
weeks and stated the residents have complained to the Administrator about the broken machine.
Observation on 12/02/19 at 6:00 P.M. of Resident #188's water pitcher in the resident's room revealed there
was no ice in the water pitcher.
Interview on 12/0219 at 11:01 A.M. with Maintenance Manager #420 revealed the ice machine in the main
dining room is accessible to the resident's but has been broken for three months.
Interview on 12/03/19 at 5:10 P.M. with State Tested Nurse Aide, (STNA) #411, revealed there was an issue
obtaining ice during the dinner service. Per the STNA the only working ice machine is located in the kitchen
and during meal preparation the aides are not able to get ice for resident's water. Per the aide the resident's
are served ice water once per shift and upon request.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365600
If continuation sheet
Page 14 of 14
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F807 - Food and drink
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
F602 - The resident has the right to be free from abuse, neglect, misappropriation of re
Protect each resident from the wrongful use of the resident's belongings or money.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
FAQ · About this visit
Common questions about this visit
What happened during the December 5, 2019 survey of LOST CREEK REHABILITATION AND NURSING CENTER?
This was a inspection survey of LOST CREEK REHABILITATION AND NURSING CENTER on December 5, 2019. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LOST CREEK REHABILITATION AND NURSING CENTER on December 5, 2019?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.