Health inspection·November 21, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm diabetes with diabetic neuropathy, unspecified fracture of shaft of left tibia, neuromuscular dysfunction of bladder, muscle weakness, essential (primary) hypertension, and major depressive disorder recurrent. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #29 was at risk of pressure ulcers and had moisture associated skin damage (MASD). Residents Affected - Few Review of the care plan revised 08/09/22 revealed Resident #29 had a potential for alternation of skin integrity with recent hospital stays, left tibia and fibula repair, decreased self-mobility, and decreased sensation of pain/pressure with neuropathy. Interventions included to complete skin assessments weekly and as needed, identify signs and symptoms of breakdown and notify appropriate staff, and observe skin for signs and symptoms of breakdown, document, and notify physician. Review of the weekly skin assessment dated [DATE] revealed Resident #29 had a small abrasion, red in color, located behind the left knee, and the resident complained it was sore. Boarder foam dressing was applied for comfort. Review of the initial wound evaluation dated 11/15/22 revealed Resident #29 was diagnosed with moisture associated dermatitis on the right buttocks and upper thigh. Treatment to include house barrier cream twice a day as needed. Review of the physician order dated 11/15/22 revealed an order for zinc to left lower buttock two times a day and as needed. There were no additional wound care orders in place to apply a dressing. Further review of the medical record revealed no documentation the physician was contacted to initiate an order for the skin breakdown on the resident's buttocks and upper thigh. Interview on 11/14/22 at 12:00 P.M. with Resident #29 revealed she had a sore on her lower buttock and stated the facility had applied a patch. Resident #29 did not have an exact date, but reported the sore had been present for months. Observation on 11/15/22 at 12:38 P.M. revealed Licensed Practical Nurse (LPN) #318 completed incontinence care for Resident #29. Continued observation revealed a skin area to left posterior upper thigh/gluteal crease which was 1-inch oval area. The area was noted to have pink tissue and within the pink tissue was an open area the size of a pencil eraser. The resident was observed to flinch when the area to the left posterior upper thigh was cleansed. LPN #318 confirmed the resident had an open area to the posterior left upper thigh/gluteal crease. Interview on 11/15/22 at 1:00 P.M. with the Director of Nursing (DON) verified the weekly skin assessment dated [DATE] was not completed accurately, as the assessment documented the wrong location for the skin breakdown and the assessment did not include measurements. The DON further verified the physician was not notified timely, and there was no order for a dressing to be applied, despite the wound assessment stating a boarder dressing was applied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 2 of 12 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 11/21/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and policy review, the facility failed to assess newly identified skin breakdown, implement interventions/treatments to aid in the healing of the existing skin breakdown, and conduct ongoing monitoring of the skin breakdown. This resulted in Actual Harm when Resident #32 was found to have a Stage III pressure ulcer to coccyx on 11/14/22 and deep tissue injuries (DTI) to right lateral foot and right lateral fifth toe. This affected one (#32) of one resident reviewed for pressure ulcers. There were a total of two residents identified by the facility with pressure ulcers. The facility census was 38. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 09/03/22 with medical diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus with diabetic neuropathy, atrial fibrillation, osteoarthritis, hyperlipidemia, Major Depression, and hypothyroidism. Review of the medical record for Resident #32 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #32 had severe cognitive impairment. The MDS revealed Resident #32 required extensive staff assist with bed mobility, transfers, ambulation, dressing, toileting, and bathing. Review of the medical record for Resident #32 revealed the resident enrolled in Hospice services 09/16/22 and changed Hospice providers on 11/14/22 per family request. Review of the medical record for Resident #32 revealed a shower sheet dated 10/24/22 that had documentation that Resident #32 had a sore that was open and red to the resident's right buttock/coccyx area. Review of the medical record revealed no documentation to support the wound was assessed or a treatment initiated. Review of the medical record for Resident #32 revealed a weekly skin assessment completed 10/26/22 which documented Resident #32 had a pressure ulcer to the coccyx but did not have documentation of the wound measurement. Further review of the medical record for Resident #32 did not have documentation to support the staff assessed the wound or contacted the physician regarding the pressure ulcer for treatment orders. Review of the medical record for Resident #32 revealed a Hospice nursing aide note dated 10/27/22 which indicated Resident #32 had a new skin issue on his bottom and the Hospice aide reported the skin issue. Review of the medical record for Resident #32 revealed a Hospice progress note dated 10/28/22 which documented the Hospice nurse was notified by facility staff that Resident #32 had several open areas on his buttocks and an area above the crease of the buttock was open. Review of the medical record revealed the Hospice nurse ordered a treatment to the wounds and stated Hospice would access the wounds with the next nurse visit. Review of the medical record for Resident #32 revealed a nurse's note dated 10/28/22 at 5:36 P.M. which documented the nurse notified Resident #32's daughter of dressing change orders due to two new areas of skin breakdown on Resident #32's bottom. Review of the medical record for Resident #32 did not contain documentation to support an assessment or measurement of the wounds were completed. Review of the medical record for Resident #32 revealed a physician order dated 10/28/22 for treatment to open areas to buttocks and coccyx. Further review of the medical record revealed the treatment order was changed on 11/01/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 3 of 12 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 11/21/2022 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of the Hospice aide visit note dated 10/31/22 revealed the Hospice aide reported Resident #32's wound to his bottom was worse than last report. Review of the Hospice note dated 11/01/22 revealed Resident #32 had a large open area to left buttock, no drainage noted. Further review of the medical record for Resident #32 revealed a Hospice aide visit note dated 11/03/22 which documented Resident #32 had a dressing over the wound to bottom. Review of the medical record for Resident #32 did not have documentation to support assessment/monitoring of wounds. Continued review of the medical record for Resident #32 revealed a Hospice nurse aide visit note dated 11/10/22 revealed Resident #32 had an area to outer right foot and nurse was notified. Review of the medical record for Resident #32 revealed a physician order dated 11/11/22 for skin prep to right outer foot. Review of the medical record did not contain documentation to support the assessment or measurement of the wound to the right lateral foot. Review of the medical record for Resident #32 revealed a progress note dated 11/10/22 at 4:00 P.M. which documented the DTI to coccyx area had U-shaped area of granulation tissue and measured 8 x 6. The note did not specify the unit of measurement used to measure the wound. Further review of the medical record for Resident #32 did not contain documentation to support the wound to the coccyx or left buttock was assessed or monitored from 10/28/22 to 11/10/22. Review of the medical record for Resident #32 revealed a Hospice assessment completed 11/14/22 which revealed the resident had a Stage III pressure ulcer to coccyx with measurements of 5 centimeters (cm) width x 4 cm length x 0.1 cm depth. The Hospice assessment did not contain documentation to support any wounds to Resident #32's right foot. An observation on 11/15/22 at 2:15 P.M. with Licensed Practical Nurse (LPN) #305 was made while LPN #305 completed a dressing change to Resident #32's wound to the coccyx. The wound was observed to be a round area on the coccyx with dark purple color on the edges of the wound and pink area inside the wound. Continued observation of Resident #32's dressing change revealed blood was noted to the old dressing. LPN #305 confirmed Resident #32's old dressing contained blood. LPN #305 confirmed the wound measurements were 5 cm x 4 cm x 0.1 cm. Interview on 11/15/22 at 9:29 A.M. with the Director of Nursing (DON) revealed the facility had not been monitoring or assessing Resident #32's coccyx wound due to the resident receiving Hospice services. The DON stated she believed the Hospice provider was assessing, monitoring, and measuring Resident #32's wound. Observation on 11/16/22 at 2:02 P.M. of State Tested Nursing Assistant (STNA) #337 examining Resident #32's right foot revealed a dressing to resident's right lateral fifth toe. The observation also revealed a dark purplish-black circle, the size of a nickel, to Resident #32's lateral right foot. Observation on 11/16/22 at 2:39 P.M. of the DON examining Resident #32's right foot revealed a dark purplish-black area, the size of a nickel, to resident's right lateral foot. Further observation included observing the DON remove the dressing to Resident #32's fifth toe on his right foot which revealed a one inch oblong dark purplish-black area to right lateral fifth toe. Review of the medical record did not have documentation to support a treatment order for the area to Resident #32's right lateral fifth toe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 4 of 12 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 11/21/2022 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 0686 Level of Harm - Actual harm Interview on 11/16/22 at 2:41 P.M. with the DON confirmed Resident #32 did not have an order for treatment to the wound on the right lateral fifth toe. The DON also confirmed the facility had not completed assessments or monitored the wounds to Resident #32's lateral right fifth toe or right lateral foot. The DON stated Resident #32's wounds to his right foot looked to be DTIs based on her observation. Residents Affected - Few Review of the Prevention of Pressure Ulcer/Injuries policy revealed the facility was to evaluate, report, and document potential changes in skin and to review the interventions and strategies for effectiveness on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 5 of 12 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 11/21/2022 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on review of the personnel files and staff interview, the facility failed to complete performance reviews for State Tested Nursing Assistants (STNA) at least once every 12 months. This affected two (STNAs #320 and #321) of two STNAs reviewed for annual performance evaluations. This had the potential to affect all 38 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for STNA #320 revealed a hire date of 02/09/18. Further review of the employee personnel file for STNA #320 revealed it did not contain documentation to support the facility completed a performance review for STNA #320 since the STNA was hired. Review of the personnel file for STNA #321 revealed a hire date of 10/31/18. Further review of the employee personnel file for STNA #321 revealed it did not contain documentation to support the facility completed a performance review for STNA #321 since the STNA was hired. Interview on 11/17/22 at 11:30 P.M. with Human Resource Director (HRD) #342 confirmed STNA #320 and STNA #321 did not have performance reviews completed in the past 12 months. HRD #342 stated she was not aware the performance reviews needed to be completed every 12 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 6 of 12 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 11/21/2022 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, staff interview, and review of facility policy, the facility failed to ensure a resident was free from the unnecessary use of an antibiotic medication. This affected one (Resident #9) of six residents reviewed for unnecessary medications. The census was 38. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 11/11/20. Diagnoses listed included schizoaffective disorder of bipolar type, Raynaud's syndrome, anxiety disorder, hypertension, major depressive disorder, and type two diabetes mellitus. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9's Brief Interview for Mental Status (BIMS) score was a 12, indicating moderate cognitive impairment. Resident #9 required extensive assistance for activities of daily living (ADLs). Review of physician orders revealed an order dated 10/15/22 for Macrobid Capsule (antibiotic) 100 milligrams (mg), give one capsule by mouth two times a day for urinary tract infection (UTI) for seven days. Review of medication administration records (MARs) revealed Resident #9 received Macrobid from 10/15/22 through 10/22/22. Further review of Resident #9's medical revealed no documentation of any signs or symptoms of an UTI. No laboratory values (labs) were documented as being obtained. Review of temperatures recorded from 10/01/22 through 10/22/22 revealed no signs of any fever. During an interview on 11/15/22 at 3:05 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #301 confirmed there was not a documented justification for the use of the antibiotic Macrobid for Resident #9. The DON stated no labs were drawn, such as an urinalysis. The DON also stated when she discovered Macrobid was started for Resident #9 on 10/15/22, the use was not addressed with the ordering Nurse Practitioner (NP). Review of the facility policy titled, Antibiotic Stewardship - Orders for Antibiotics, dated revised December 2016 revealed appropriate indications for the use of antibiotics include, criteria met for clinical definition of active infection or suspected sepsis, and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 7 of 12 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 11/21/2022 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 0791 Provide or obtain dental services for 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, resident interview, staff interview, and contract dental provider interview, the facility failed to ensure residents received routine dental services. This affected two (Residents #17 and #29) of two residents reviewed for dental services. The facility census was 38. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included primary generalized osteoarthritis, dementia unspecified severity with agitation, schizophrenia, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Interview on 11/14/22 at 1:50 P.M. with Resident #17 revealed there was a delay in scheduling a dental appointment and his teeth had been removed. Resident #17 stated he had been wanting dentures. Review of dental notes dated 07/01/21 revealed Resident #17 met with the dentist and was referred for extractions. Review of dental notes dated 09/08/22 revealed Resident #17 had extractions completed and was referred for dentures. Interview on 11/15/22 at 10:14 A.M. with Social Services #303 revealed typically the dentist is scheduled every three months. Social Services #303 reported the dental provider had a previous email contact and there were no appointments scheduled. Interview on 11/16/22 at 3:24 P.M. with Contract Dental Staff #344 verified Resident #17 was referred for extractions and dentures on 07/01/21 and was not seen again until 09/08/22. Contract Dental Staff #344 verified there was no documentation stating why there was a delay in services. 2. Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included unspecified fracture of shaft of left fibula subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, chronic respiratory failure with hypoxia, type two diabetes with diabetic neuropathy, unspecified fracture of shaft of left tibia, neuromuscular dysfunction of bladder, muscle weakness, essential (primary) hypertension, and major depressive disorder recurrent. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Interview on 11/14/22 at 10:46 A.M. with Resident #29 revealed the resident had tooth concerns, reporting there were holes in the back of her teeth. Resident #29 stated she had not been offered dental services and would like to have a dental appointment. Further review of the medical record revealed no documentation showing facility staff offering to set up dental services for Resident #29. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 8 of 12 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 11/21/2022 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 0791 Interview on 11/17/22 at 9:53 A.M. with Social Services #303 verified Resident #29 had not been approached regarding accepting or refusing dental services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 9 of 12 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 11/21/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of facility policy, review of community transmission rate, review of Centers of Medicare and Medicaid Services (CMS) memorandum QSO-23-02-ALL, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore face masks as required to potentially prevent the spread of Coronavirus 2019 (COVID-19). This had the potential to affect all 38 residents residing in the facility. Residents Affected - Many Findings include: Review of the CDC COVID-19 Integrated County View revealed on 11/14/22, the facility's county community transmission rate was high. Observation on 11/14/22 at 7:58 A.M. revealed upon entrance to the facility, unidentified staff and residents were in the common area with no face masks applied. Human Resources #342 approached and Surveyor staff and reported they may continue to wear Personal Protective Equipment (PPE) if desired, but the facility did not require anyone to wear PPE at this time. Observation on 11/14/22 at 8:35 A.M. revealed the Administrator, Director of Nursing (DON), and Registered Nurse (RN) #345 were in resident care areas with no face masks applied. Interview on 11/14/22 at 8:40 A.M. with the DON verified staff were not wearing face masks in resident care areas. The DON stated she checked the data this morning, and the community transmission rate was not high, therefore the facility staff were not required to wear face masks. Upon review of the data tracker website, the DON verified the community transmission rate was indeed high. Review of the CMS COVID Data Tracker website, reviewed 11/14/22, verified the community transmission rate for the facility's county was high. Review of facility policy titled, COVID-19 Policy and Procedure, updated 09/23/22 verified all staff members are to wear personal protective equipment based on community transmission if the facility is in a county with high community transmission, they are required to be in a surgical mask. Review of CMS memorandum QSO-20-39-NH dated 09/23/22 verified if the nursing home's county COVID-19 community transmission is high, everyone in a healthcare setting should wear face coverings or masks. Review of CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/23/22 revealed when SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 10 of 12 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 11/21/2022 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of facility policy, review of community transmission rate, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure new admissions were tested for Coronavirus 2019 (COVID-19) upon admission. This affected one (Resident #289), identified as a new admission, and had the potential to affect all 38 residents in the facility. Residents Affected - Many Findings include: Review of Resident #289's medical record revealed an admission date of 11/07/22. Diagnoses listed included chronic obstructive pulmonary disease, protein-calorie malnutrition, osteoarthritis, hypertension, and hyperlipidemia. Further review of the medical record revealed no documentation Resident #289 was tested for COVID-19 upon admission. Resident #289 was not vaccinated for COVID-19. Interview on 11/16/22 at 4:08 P.M. with the Director of Nursing and Licensed Practical Nurse (LPN) #301 verified the facility had not been testing new admissions for COVID-19. LPN #301 verified Resident #289 was not tested for COVID-19 upon admission or as required. Review of the CDC COVID-19 Integrated County View revealed on 11/07/22, the facility's county community transmission rate was high. Review of the Centers for Medicaid and Medicare Services (CMS) COVID Data Tracker website, reviewed 11/14/22, verified the community transmission rate for the facility's county was high. Review of facility policy titled, COVID-19 Policy and Procedure, updated 09/23/22 verified admissions in counties where community transmission levels are high should be tested upon admission. Testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. Review of the CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/23/22 verified testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. In general, admissions in counties where community transmission levels are high should be tested upon admission; admission testing at lower levels of community transmission is at the discretion of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 11 of 12 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 11/21/2022 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 0947 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of the personnel files and staff interview, the facility failed to conduct 12 hour in-service training for State Tested Nursing Assistants (STNA) per year. This affected two (STNAs #320 and #321) of two STNAs reviewed for 12 hour in-service training. This had the potential to affect all 38 residents residing in the facility. Findings include: Review of the personnel file for STNA #320 revealed a hire date of 02/09/18. Further review of the employee personnel file for STNA #320 revealed it did not contain documentation to support the facility completed 12 hour in-service training since STNA #320's hire date. Review of the employee personnel file for STNA #321 revealed a hire date of 10/31/18. Further review of the employee personnel file for STNA #321 revealed it did not contain documentation to support the facility completed 12 hour in-service training since STNA #321's hire date. Interview on 11/17/22 at 11:30 P.M. with Human Resource Director (HRD) #342 confirmed STNA #320 and STNA #321 did not contain documentation to support the facility completed 12 hour in-service training since the STNAs hire dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 12 of 12