Inspection·February 8, 2024

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 immunization records, staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered influenza and pneumococcal vaccinations per CDC recommendations. This affected four (Residents #9, #17, #22, and #48) of five reviewed for influenza and pneumococcal vaccination. The facility census was 40. Residents Affected - Some Findings include: 1. Review of the closed medical record revealed Resident #9 was admitted on [DATE] and discharged on 11/27/23. Diagnoses included alcoholic cirrhosis of liver with ascites, COVID-19, thrombocytopenia, muscle weakness, alcohol induced acute pancreatitis without necrosis or infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the Patient Vaccination Informed Consent/Declination form signed 09/22/23 revealed Resident #9 consented to the influenza vaccine. Review of the vaccination record revealed Resident #9 did not receive the influenza vaccine. 2. Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included rhabdomyolysis, type two diabetes mellitus without complications, dysphagia oropharyngeal, atherosclerotic heart disease of native coronary arterly without angina pectoris, hypothyroidism. Review of the MDS assessment 11/08/23 revealed the resident was cognitively intact. Review of the current immunization record located in the electronic medical record (EMR) revealed no documentation the resident had been offered or received the influenza or pneumococcal vaccines. 3. Review of the medical record revealed Resident #22 was initially admitted on [DATE] with re-entry on 4/30/22. Diagnoses included acute chronic diastolic (congestive) heart failure, type two diabetes mellitus with diabetic neuropathy, muscle weakness, lymphedema, and chronic kidney disease stage 3. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. In addition, Resident #22 was not up to date on the pneumococcal vaccine and it had not been offered. (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 4 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 02/08/2024 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)