Health inspection·November 21, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and resident interview the facility failed to ensure residents were provided with dignity during dining. This affected six (#7, #57, #92, #113, #129 and #358) of 30 residents reviewed for dining. The facility census was 152. Findings include: 1. Record review revealed Resident #92 was admitted to the facility on [DATE]. Diagnoses included dementia, paranoid schizophrenia, anxiety and chronic kidney disease. Review of the quarterly assessment dated [DATE] revealed the resident had impaired cognition, and required supervision to eat. Review of the nurse notes dated from 08/01/19 to 11/20/19 had no documentation to support staff were being rude or disrespectful, however notes throughout documented the resident was frequently upset with staff for not being able to hear what she was saying. Observation on 11/20/19 at 7:49 A.M., Resident #92 was sitting at the table in the dining area, and State Tested Nursing Assistant (STNA) #326 had just set down a bowl of cold cereal, a glass of juice and a glass of milk. STNA #326 then sat at the table next to Resident #92 and began looking over dining tickets. Resident #92 stated she had told STNA #326 she did not want any milk and the STNA needed to come and take it away. STNA #326 responded to the resident with a direct stern tone that she would take the milk away in a minute and that the resident could hold on. STNA #326 made eye contact with the surveyor the her tone immediately changed. STNA #326 continued to tell the resident she had not put the milk in her cereal and knew the resident wanted to eat it dry. Resident #92 was eating dry cereal and the milk was not poured in the bowl. Interview on 11/20/19 at 7:50 A.M., STNA #326 apologized for sounding stern, and said she should not have done that. She also stated she had not poured the milk in the cereal and was going to take away the milk when she was finished with the dietary tickets for other residents. Interview on 11/20/19 at 8:05 A.M., the Administrator and Director of Nursing (DON) were made aware of the interaction between STNA #326 and Resident #92. They both stated they have zero tolerance for rudeness or disrespect and they were going to begin to investigate and provided education immediately. Interview on 11/20/19 at 2:40 P.M., Resident #92 stated STNA #326 did not like it when she told her (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 5 Event ID: 365346 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 365346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036 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)