Health inspection·June 9, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of policy titled, Answering the Call Light, revised October 2010 revealed be sure the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 2 of 18 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 06/09/2025 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation and interview the facility failed to ensure there was a visible posting on where to locate the survey results. This had the potential to affect all residents. The facility census was 39. Residents Affected - Many Findings include: Observation on 06/04/25 at 2:27 P.M. of the front lobby revealed three black letter holders hanging on the wall between the business office and the admissions office with a binder with a small label that stated survey results. Black binder was not easily identified as the survey results unless you were right up on it. No signage observed indicating where the binder is located. Interview on 06/05/25 at 8:09 A.M. with the Administrator verified there was no signage in the lobby or common area to indicate where the survey results were located. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 3 of 18 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 06/09/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the hard chart and the electronic medical record contained the correct advance directive information. This affected one (#27) of 21 residents reviewed for advanced directives. The facility census was 39. Findings include: Review of medical record for Resident #27 revealed an admission date of 03/31/25 with diagnoses including but not limited to Parkinson's disease, muscle weakness, hypertension, other specified forms of tremor, and thrombocytopenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed the resident was a full code. Review of hard chart for Resident #27 revealed the resident was a Do Not Resuscitate Comfort Care Arrest (DNR CCA). Review of care plan dated 04/18/25 revealed the residents advanced directive: DNR CCA with interventions including but not limited to acknowledge and maintain resident wishes regarding advanced directives and assess advanced directive upon admission, quarterly, annually, and with significant change to ensure resident wishes are maintained regarding advanced directive. Interview on 06/03/25 at 11:27 A.M. with the Director of Nursing (DON) verified the physician order was for a full code and the hard chart had a DNRCCA form signed by the physician. Review of policy titled Advance Directives updated 03/17/25 revealed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 4 of 18 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 06/09/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide a discharge notice and notice of transfer to residents, residents' representatives, and the Ombudsman. This affected two residents (#28 and #42) out of four residents reviewed for notices. The facility census was 39. Findings include: 1. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Diagnoses for Resident #28 include diabetes type two, paraplegia, chronic obstructive pulmonary disease, pain, and schizoid personality disorder. Review of Resident #28's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of Resident #28's progress note dated 06/01/25 at 2:10 A.M. the nurse documented Resident #28 had a change in condition with declining vital signs and was transferred to the hospital via emergency squad at 2:30 P.M. Per the note dated 06/01/25 at 3:11 P.M. the nurse documented Resident #28 had been admitted to the hospital post fall. Further review of Resident #28's medical records revealed there was no evidence of any transfer summary dated from 06/01/25 to 06/05/25 sent to the hospital, resident, resident's representative, or the Ombudsman. Interview on 06/05/25 at 3:30 P.M. with Managed Care Provider (MCP) #903 verified there was no transfer notification to Resident #28, the resident's family representative, or the Ombudsman. 2. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses for Resident #42 include complications post surgery to repair a femur fracture, depression, and myeloma. Review of Resident #42's MDS dated [DATE] revealed the resident had mildly impaired cognition. Review of Resident #42's progress notes dated 03/14/25 revealed Resident #42's sister notified the facility Resident #42 was transferred and admitted to the hospital from her outside physician appointment due to syncopal episode and possible urinary tract infection. Further review of Resident #42's medical records revealed no evidence of any notification of discharge or transfer to the resident, resident's representative or the Ombudsman. Interview on 06/04/25 at 11:22 A.M. with Administrator verified there was no discharge or transfer summary documented for Resident #42. The Administrator verified Resident #42 was discharged from the facility as of 03/14/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 5 of 18 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 06/09/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed accurately. This affected one (#10) of one resident reviewed for PASARR. The facility census was 39. Findings include: Review of medical record for Resident #10 revealed an admission date of 11/11/20 with diagnoses including but not limited to bipolar disorder current episode depressed mild or moderate severity, schizoaffective disorder bipolar type, visual hallucinations, altered mental status, auditory hallucinations, cognitive communication deficit, inadequate social skills, anxiety, and adult antisocial behavior. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed depakote 500 milligrams (mg) at bedtime (bipolar), depakote 250 mg twice a day (bipolar), duloxetine 40 mg twice a day (depression), risperidal 0.5 mg at bedtime (hallucinations), seroquel 100 mg twice a day in the afternoon and bedtime (bipolar and schizoaffective disorder), and seroquel 300 mg half a tablet in the morning. Review of Preadmission Screening and Resident Review (PASARR) dated 01/07/24 revealed the only diagnoses listed were mood disorders and panic or other severe anxiety disorders. No psychotropic medications were listed on the PASARR. Interview on 06/04/25 at 01:50 P.M. with Managed Care Coordinator (MCC #903) revealed they verified the PASARR did not include any psychotropic medications for Resident #10. MCC #903 verified there were no other diagnoses included besides mood disorder and panic or other severe anxiety disorders. Review of policy titled, Resident Assessment - Coordination with PASARR Program, dated October 2024 revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 6 of 18 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 06/09/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on record review and interview the facility failed to implement a baseline care plan that included all care concerns from admission. This affected one (#96) of three residents reviewed for baseline care plan. The facility census was 39. Findings include: Review of medical record for Resident #96 revealed an admission date of 06/01/25 with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation, chronic ischemic heart disease, bacteremia, heart failure, chronic kidney disease stage four, atrial fibrillation, and obstructive sleep apnea. Review of current physician orders revealed ampicillin sodium injection solution 2 grams (gm) intravenous (IV) every eight hours for implantable cardioverter-defibrillator (ICD) infection until 06/30/25, ceftriaxone 2000 milligrams (mg) IV twice daily for ICD infection, change life vest (wearable cardioverter defibrillator) battery every 24 hours during evening shift, check life vest back-up battery pack is getting charged every shift, check life vest placement every shift, and change peripherally inserted central catheter (PICC) dressing and caps weekly. Review of baseline care plan dated 06/01/25 revealed no care plan for the PICC line, life vest, infection, or receiving any antibiotics which were all present on admission. Interview on 06/04/25 at 01:25 P.M. with Director of Nursing (DON) verified the resident was on IV antibiotics, had an actual infection, and was wearing a life vest on admission and should be reflected in the baseline care plan. DON verified the above was not included on the baseline care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 7 of 18 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 06/09/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure quarterly care conferences were held including the families, residents, and interdisciplinary team and failed to ensure care conferences were held timely. This affected five (#10, #16, #33, #5, and #6) of 21 residents reviewed for care conferences. The facility census was 39. Findings include: 1. Review of medical record for Resident #10 revealed an admission date of 11/11/20 with diagnoses including but not limited to bipolar disorder current episode depressed, mild or moderate severity, schizoaffective disorder bipolar type, type two diabetes, visual hallucinations, altered mental status, auditory hallucinations, cognitive communication deficit, inadequate social skills, adult antisocial behavior, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of care conference documentation revealed a care conference was held on 01/31/24, 05/29/24, 09/12/24, 12/05/24, 02/05/25, and 05/21/25. Care conferences were held with dietary, social worker, and activities. Interview on 06/02/25 at 04:24 P.M. with Resident #10 revealed they do not have care conference meetings with her or her family that she can remember. 2. Review of medical record for Resident #16 revealed an admission date of 02/05/19 with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes, asthma, cervicalgia, congestive heart failure, unspecified mood affective disorder, and hypertension. Review of MDS dated [DATE] revealed the resident was cognitively intact. Review of care conferences revealed conferences were held on 02/14/24, 06/26/24, 09/26/24, and 02/26/25 with only dietary, social services, and activities attending. Interview on 06/02/25 at 10:17 A.M. with Resident #16 revealed they do not hold care conferences any more. Resident #16 stated she has not had one in about a year. 3. Review of medical record for Resident #33 revealed an admission date of 02/26/25 with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting non-dominant left side, chronic obstructive pulmonary disease, type two diabetes, atrial fibrillation, hypertension, bipolar disorder, and congestive heart failure. Review of MDS dated [DATE] revealed a BIMS score of 13 which indicated the resident was cognitively intact. Review of medical record revealed no care conferences have been held. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 8 of 18 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 06/09/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Interview on 06/02/25 at 3:12 P.M. with Resident #33 and spouse revealed they have never had a care conference since admission. Interview on 06/03/25 at 1:25 P.M. with the Administrator revealed Resident #33 has not had any care conferences scheduled. Residents Affected - Some Interview on 06/05/25 at 1:37 P.M. with Managed Care Coordinator (MCC #903) verified the care conferences were not attended by the interdisciplinary team (IDT). MCC #903 verified Resident #10 and Resident #16 care conferences were not held every three months. MCC #903 verified the facility did not send out letters for care conferences with the date and time of the conference. MCC #903 stated they would just tell the resident when the care conferences were going to be held. 4. Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #5 include cerebral palsy, chronic obstructive pulmonary disease, dysphagia, and contractures. Review of Resident #5's Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #5's contact census in the medical record revealed the resident was listed as his own person and can make his own medical decisions. Review of Resident #5's progress notes dated 05/28/25 revealed Social Worker (SS) #651 documented the resident's had a care conference meeting, see specifics in care conference assessment. Review of Resident #5's care conference assessment dated [DATE] revealed the meeting was documented in the form as being held on 05/28/25 at 11:00 A.M. Per the assessment, staff who attended included a Registered Nurse, activity staff, dietary staff, and the social worker. No family or resident was documented as having been invited or attending the meeting. No concerns from resident or family were documented in the assessment. Interview on 06/02/25 at 11:17 A.M. with Resident #5 revealed the resident stated he did not know if he had every attended a care conference meeting with the staff at the facility. Resident #5 denied being invited to a care conference per his knowledge. Interview on 06/03/25 at 3:30 P.M. with Social Services (SS) #651 verified Resident #5 had not been in attendance for his 05/28/25. SS #651 verified there was no documentation his family or the resident had been invited and there was no documented input or concerns in the assessments from Resident #5. 5. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #6 include cerebral infarction, hypertension, dysphagia, pain, and falls. Review of the progress notes dated 05/07/25 at 1:30 A.M. the social worker wrote Resident #6 had a care conference on 05/07/25. Review of the history of the note revealed the progress note was created and signed on 05/22/25 at 1:08 P.M. Review of the progress note dated 05/07/25 at 8:48 A.M. revealed the social worker contacted Resident #6's son, family representative, to invite him to attend the care conference and the son stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 9 of 18 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 06/09/2025 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 0657 he will not be able to attend. Per the note the son voiced concerns and the concerns will be followed up. Level of Harm - Minimal harm or potential for actual harm Interview on 05/02/25 at 3:14 P.M. with Resident #6's son stated he could not recall when the last time he attended a care conference with the staff at the facility. Per the son, he could not recall any invitations to any care conferences in the year 2025. Residents Affected - Some Interview on 06/03/25 at 3:30 P.M. with SS #651 verified there was missing documentation in Resident #6's most recent 05/07/25 care conference assessment. Per SS #651, the social worker held the care conference with dietary staff, the social worker, and activities. SS #651 verified there was no nurses or aides in the care conference. SS #651 verified Resident #6 did not attend the care conference. SS #651 stated she had contacted the resident's family representative the day prior to the care conference and the son reported he could not attend due to not having enough notice of time for the care conference. SS #651 verified when the care conferences are scheduled they are held with available staff and residents and their family representative sometimes are not able to attend and the social worker does not reschedule the meetings. SS #651 verified some care conferences do not include nurses and no aides come to the conferences. Review of policy titled, Resident Participation - Assessment/Care Plans, revised December 2016 revealed the resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to participate in the planning process, identify individuals to be included in the planning process, request meetings, request revisions, participate in establishing his or her goals and expected outcomes of care, participate in the type, amount, frequency, and duration of care, receive the services and/or items included in the care plan, have access to and review the care plan, and be informed of, review and sign the care plan after any significant changes are made. The care planning process will facilitate the inclusion of the resident and/or representative, include an assessment of the resident's strengths and his or her needs, and incorporate the resident's personal and cultural preferences in establishing goals of care. A seven day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: the date, time, and location of the conference, the name of each person contacted and the date he or she was contacted, the method of contact (mail, telephone, email), input from the resident or representative if they are not able to attend, refusal of participation, if applicable, and the date and signature of the individual making the contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 10 of 18 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 06/09/2025 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 medical record review, observation, staff interviews, and review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, the facility failed to monitor a resident's leg where a brace was applied. This resulted in actual harm when the resident developed a Deep Tissue Injury (DTI) later resulting in a stage four pressure ulcer (deep wound that may impact muscle, tendons, ligaments, and bone) that ultimately required two surgical debridements in an attempt to promote wound healing. This affected one (#9) of three residents reviewed for pressure wounds. The facility census was 39. Residents Affected - Few Findings include: Review of medical record for Resident #9 revealed an admission date of of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed wound treatment to right upper lateral calf was to cleanse with soap and water, pat dry and apply calcium alginate to the wound bed, cover with abdominal (ABD) pad and wrap with kerlix, weight bearing as tolerated (WBAT) to right lower extremity while in knee brace with walker (03/19/25-04/16/25), liquid protein 30 milliliters (ml) daily for wound healing. Review of the care plan dated 03/26/25 revealed the resident is at risk for skin breakdown related to increased need for assistance with bed mobility and transfers, neuropathy, peripheral vascular disease, and right lateral calf pressure. Interventions included apply lotion/moisture barrier cream as needed, can transition out of brace, WBAT to right lower extremity with walker, encourage to float heels as tolerated, observe skin for redness or open areas notify the nurse, skin assessment as needed, supplements per order, and turn and reposition every two hours as tolerated. Review of a general progress note dated 02/19/25 at 2:02 P.M. revealed the resident returned from an orthopedic appointment with order indicating okay to put right foot down for balance. Continue physical therapy (PT) and occupational therapy (OT). No Range of Motion (ROM) to right knee. Continue brace. Follow up in one month. Review of a general progress note dated 03/19/25 at 1:42 P.M. revealed the resident returned from an orthopedic appointment with new order to begin Weight Bearing as Tolerated (WBAT) to right lower extremity in the knee brace. Okay for ROM to right knee and continue PT/OT. Review of a general progress note dated 04/16/25 at 3:00 P.M. revealed the resident returned from an orthopedic appointment with new order to transition out of knee brace. WBAT to right lower extremity with walker. Continue with PT/OT. Review of a general progress note dated 04/17/25 at 11:58 A.M. revealed Certified Nursing Assistant (CNA) reported the resident had a skin tear on the outer right calf caused by the brace. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 11 of 18 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 06/09/2025 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 is to transition out of the brace and therapy is working with the resident towards that goal. Steristrips applied. Level of Harm - Actual harm Residents Affected - Few Review of a general progress note dated 04/20/25 at 8:41 P.M. revealed this order was updated to cleanse and apply border foam to right outer calf. This nurse went to treat the area and found that the skin flap is slothing off and area had opened. Area measured 4.7 centimeters (cm) by 5.4 cm, area warm, seeping and plus two pitting edema compared to left leg at plus one pitting edema. Daughter present in room and explained they will await treatment plan and the resident could be seen by the in-house wound physician. Review of the wound physician note dated 04/21/25 revealed an unstageable wound to right upper lateral calf full thickness. Wound was a pressure wound. Wound measured 7.0 cm length by 5.9 cm width with a non measurable depth. Surface area 41.30 cm squared. Periwound surrounding deep tissue injury (purple/maroon). Moderate serous exudate. Thick adherent black necrotic tissue 60 percent (%), granulation tissue 40% with no pain or signs of infection. Treatment plan santyl apply once daily and as needed if saturated, soiled, or dislodged for 30 days and cover with gauze island with border dressing once daily and as needed. Reason for no sharp debridement chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor for now. Recommended lower extremity arterial Doppler. Review of wound physician note dated 04/28/25 revealed a stage four pressure wound to the right upper lateral calf full thickness. Per note patient had a fractured femur for which the resident was wearing a brace. The pad of the brace created a pressure wound on the calf. Wound measured 7.0 cm length by 6.0 cm width by depth is unmeasurable due to presence of non-viable tissue and necrosis. Surface area 42.00 cm squared. Periwound induration and maceration. Light serous exudate. 100% thick adherent black necrotic tissue. No pain or signs of infection observed. Debridement procedure completed to remove necrotic tissue and establish the margins of viable tissue, remove thick adherent eschar and devitalized tissue, and remove hematoma. Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a stage 4 pressure injury. This is not a wound deterioration. Lower extremity arterial Doppler left and right performed on 04/28/25 with mild to moderate peripheral vascular disease without occlusion in the right lower leg. Review of the wound physician note dated 05/05/25 revealed a stage four pressure wound to the right upper lateral calf full thickness measuring 6.8 cm length by 5.8 cm width by 0.7 cm in depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased necrotic tissue and decreased surface area. No pain or signs of infection. Review of the wound physician note dated 05/12/25 revealed a stage four pressure wound to the right upper lateral calf full thickness measuring 7.0 cm length by 5.6 cm width by 0.4 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 05/19/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 6.9 cm length by 5.0 cm width by 0.3 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 12 of 18 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 06/09/2025 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 Review of the wound physician note dated 05/26/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 6.5 cm length by 4.5 cm width by 0.2 cm depth with light serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Residents Affected - Few Review of the wound physician note dated 06/02/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 5.8 cm length by 3.8 cm width by 0.1 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Surgical excisional debridement completed. The wound was cleansed with normal saline and anesthesia was achieved using topical bensocaine. Curette was used to surgically excise devitalized tissue and necrotic tissue subcutaneous level tissues were removed to a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 3% to 0%. Hemostasis was achieved and a clean dressing was applied. Interview on 06/04/25 at 8:39 A.M. with the Director of Nursing (DON) revealed the resident's brace came off every night at bedtime. The DON stated the nurses would look at the residents skin then. The DON stated that two days prior to the wound being discovered, she treated a skin tear. The DON stated she then treated another skin tear by cleaning the wound and applying Steristrips and kerlix. The DON stated that approximately two days later she was notified that the area was open and bleeding. The DON stated that when she cleaned the skin tear she thought the wound looked weird as the skin appeared to be darker. The DON stated the wound doctor saw the resident the next day and he removed what they thought was a big clot. Further review of the medical record revealed no evidence the facility was removing the brace at night and checking the skin around the brace on a daily basis. Interview on 06/04/25 at 3:18 P.M. with the DON and Assistant Director of Nursing (ADON #403) revealed they both verified the wound was caused by the brace. ADON #403 stated if you lined up the brace the wound was located where the dial of the brace was located. The DON verified they could have padded the area that the dial was on had they realized it would or was causing pressure. The DON verified the wound was staged by the wound physician. The DON verified the weekly wound documentation prior to the discovery of the deep tissue injury did not contain any lesions or open areas to the right lower extremity and on 04/20/25 there was documentation of a skin tear to the area. The DON verified there was no supporting documentation regarding the removal of the brace for care or skin assessments under the brace. Review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, dated February 2020, indicates, in part, the following: Inspect the skin under and around the device at least daily (if not medically contraindicated); Cushion and protect the skin with dressings in high risk areas; Be aware of edema under the device(s) and potential for skin breakdown; and Educate staff on correct use of devices and prevention of skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 13 of 18 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 06/09/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident had the mental capacity to sign into an arbitration agreement and further failed to explain arbitration agreements in a language that the residents would understand. This affected three (#9, #25, and #31) of five residents reviewed for arbitration agreements. The facility census was 39. Residents Affected - Few Findings include: 1. Review of medical record for Resident #9 revealed an admission date of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of arbitration agreement revealed the agreement was signed on 02/03/25 by the resident. Interview on 06/05/25 at 10:09 A.M. with Resident #9 revealed the resident did not know what an arbitration agreement was. Resident #9 stated he could not remember if the facility explained it to him. Resident #9 stated he did not know if he would sign one or not. 2. Review of medical record for Resident #25 revealed an admission date of 02/06/24 with diagnoses including but not limited to pneumonia, type two diabetes, unspecified asthma, paraplegia, heart failure, and atrial fibrillation. Review of MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of arbitration agreement revealed the resident signed the agreement on 02/19/25. Interview on 06/04/25 at 02:08 P.M. with Resident #25 revealed an arbitration agreement is that if they have a disagreement with the facility it goes to the judge and they argue the points and the decision of the judge is final. Resident #25 stated it takes place in a court. Resident #25 stated he is unsure if he signed one when he came to the facility. 3. Review of medical record for Resident #31 revealed an admission date of 09/20/23 with diagnoses including but not limited to ischemic heart disease and dementia without behavioral disturbances. Review of MDS dated [DATE] revealed a BIMS score of 03 which indicated the resident had severe cognitive impairment. Review of arbitration agreement dated 02/19/25 revealed the agreement was signed by the resident. Interview on 06/04/25 at 01:43 P.M. with the Administrator revealed they are currently the one responsible for doing the arbitration agreements. Administrator stated she would explain to the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 14 of 18 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 06/09/2025 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that if they do not understand the arbitration agreement they do not have to sign it. Administrator stated she does not usually explain the agreement to them she would have them read it. Follow-up interview on 06/04/25 at 01:52 P.M. with the Administrator revealed that she would have the resident read the arbitration agreement and explain to the resident that it is their legal right to voluntarily obtain legal council prior to signing and they do not have to sign the agreement. Interview on 06/05/25 at 10:20 A.M. with Resident #31 revealed the resident did not know exactly what an arbitration agreement was. Resident #31 stated he did not remember signing one. Interview on 06/05/25 at 11:04 A.M. with the previous admission Director (AD #905) revealed that she would explain the arbitration agreement to the resident. AD #905 stated she would let the residents know it was voluntary and if they wanted to obtain legal council prior to signing it would be okay. AD #905 stated she would explain to the resident if they had an issue with the facility or their care they would go to an arbitrator instead of going to court. AD #905 stated she would let them know it would be faster and cheaper for both parties. AD #905 stated if the resident did not understand the agreement she would go to the next of kin or responsible party. Interview on 06/05/25 at 11:27 A.M. with Regional Director of Operations (RDO #902) verified that Resident #31 had a BIMS score of three and the power of attorney should have signed the second agreement as well. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 15 of 18 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 06/09/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure proper handwashing, cleansing of re-usable equipment, and proper glove use was followed during resident care. This affected two residents (#23 and #9) out of five residents reviewed for infection control protocols. The facility census was 39. Residents Affected - Few Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include neoplasm of nervous system, anxiety, urinary tract infection, dysphagia, and weakness. Review of Resident #23's Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition and was receiving enteral nutrition via a feeding tube. Review of Resident #23's care plans dated 12/11/24 revealed a focus for Enhanced Barrier Precautions (EBP) protocols due to indwelling medical device. Intervention include signage placed on doorway and gloves and gown to be worn during direct care with resident. Observation on 06/05/24 at 9:00 A.M. with Licensed Practical Nurse (LPN) #511 revealed the nurse prepared the supplies for the feeding tube care. LPN #511 was observed placing on a gown and gloves prior to entering Resident #23's room. LPN #511 was not observed sanitizing her hands prior to applying the gloves. LPN #511 was observed discontinuing the feeding solution on the pump, removing the old tubing from the resident's feeding tube catheter. LPN #511 did not change her gloves during the care. LPN #511 was observed retrieving a syringe from the resident's bathroom, and filling a plastic cup with water to 150 milliliters. LPN #511 was observed checking the placement of the feeding tube with a stethoscope, checking the residual amount of tube feeding, and flushing the tube with 150 milliliters of water. LPN #511 was not observed washing her hands or changing her gloves during the care observed. LPN #511 was observed taking all supplies back into the bathroom and retrieving a new gauze pad. LPN #511 was observed opening the gauze pad and then stated she should change her gloves before applying the new bandage. LPN #511 was observed removing the current set of gloves and then put on a new set of gloves. LPN #511 did not use hand sanitizer or wash her hands in between the application of gloves. Interview on 06/05/25 at 9:25 A.M. with LPN #511 verified she only used one pair of gloves during most of the care provided until she applied the new bandage to the tube feeding site. LPN #511 stated it was protocol to wash her hands and apply new gloves frequently during the care she provided. LPN #511 verified she did not sanitize or wash her hands during the care of Resident #23's feeding tube. 2. Review of medical record for Resident #9 revealed an admission date of of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 16 of 18 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 06/09/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of current physician orders revealed wound treatment to right upper lateral calf was to cleanse with soap and water, pat dry and apply calcium alginate to the wound bed, cover with ABD pad and wrap with kerlix. Observation on 06/04/25 at 11:39 A.M. of Registered Nurse (RN #506) completing wound care for Resident #9 revealed the nurse placed a clean barrier on the over the bed table and placed one new wash basin with soap and water onto the barrier. RN #506 placed a second new wash basin with rinse water beside the other one on the clean barrier. RN #506 placed the dressing supplies (package of kerlix, box of silver alginate, and ACE bandage) on the clean barrier. Nursing student precepting with the nurse was also in the room. RN #506 washed hands, donned gown and gloves and cleansed the wound to right calf with soap and water and rinsed the wound. Wound appeared to be beefy red in the bed of the wound. Wound edges were slightly macerated but intact. RN #506 removed her gloves, washed hands, and donned new gloves. RN #506 then patted the wound dry. RN #506 removed gloves, washed hands, and donned new gloves. RN #506 then touched the box of silver alginate dressings and pulled out one package of the silver alginate. RN #506 opened the package of silver alginate and placed the silver alginate into the wound bed. RN #506 then removed the dressing to cut the dressing to size with scissors that were removed from the student nurse preceptors pocket. The nurse was not observed cleansing the scissors prior to cutting the dressing. RN #506 then placed the dressing back in the wound bed and removed it for a second time to cut more off to fit it to the wound size. RN #506 then placed the dressing into the wound bed and placed an ABD pad over the silver alginate and wrapped the wound with kerlix. RN #506 then wrapped the leg with ACE bandage. RN #506 then cleaned up the area and removed gloves, washed hands and removed the trash from the room. Interview on 06/04/25 at 11:52 A.M. with RN #506 revealed the nurse verified she placed the dressing in the wound bed and removed it to cut it to size so the dressing would not touch good skin twice. RN #506 verified the student pulled her scissors out of her pocket and did not sanitize them prior to cutting the dressing. RN #506 verified she touched the box of silver alginate and pulled out one package without changing gloves or washing hands prior to placing the dressing into the wound bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 17 of 18 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 06/09/2025 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 - Minimal harm or potential for actual 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 employee file review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of inservices annually. This affected two (CNA #510 and CNA #519) of three CNA employee files reviewed. This had the potential to affect all residents who reside in the facility. The facility census was 39. Findings include: Review of employee file for CNA #510 revealed a hire date of 01.09/23. Review of education file revealed the CNA #510 did not complete 12 hours of inservices annually. Review of employee file for CNA #519 revealed a hire date of 10/10/23. Review of education file revealed the CNA #519 did not complete 12 hours of inservices annually. Interview on 06/09/25 at 11:05 A.M. with Medical Records #655 verified the facility could not locate any documentation regarding the 12-hour inservices for CNA #510 and CNA #519 for 2024 and 2025. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365600 If continuation sheet Page 18 of 18