Health inspection·August 18, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medical record review, staff interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure care plans were updated to reflect residents' current status. This affected two (Residents #10 and #28) of two reviewed for care plan revisions. The facility census was 84. Findings include: 1. Review of the medical record for Resident #10 revealed admission date 02/23/22. Diagnoses included Guillain-Barre Syndrome, quadriplegia, cognitive communication deficit, muscle weakness, dysphagia, type II diabetes, heart failure, depression, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two people for bed mobility and extensive assistance of one person for transfers. The resident had no falls since admission/re-entry. Review of the Nursing Fall Review dated 07/10/22 revealed Resident #10 had a recent fall while getting out of her bed and into her wheelchair. Immediate intervention included to put gripper socks on the resident. The resident was considered to be at moderate risk for falls. Review of Resident #10's care plan dated 06/15/22 revealed the resident was at moderate risk for falls related to de-conditioning and gait/balance problems. Interventions included to anticipate and meet the resident's need, ensure call light is within reach and encourage the resident to use it for assistance, respond to the resident's needs promptly, educate on the importance of calling for assistance prior to transferring, ensure PRAFO (a device that is worn on the calf and foot, similar to a boot) on while in bed as tolerated, ensure ankle foot orthosis (AFO) bracing orthotic therapy for mild to moderate joint stiffness, contracture, or spasticity of the ankle and foot) while up during day as tolerated, monitor skin/pain, perimeter mattress to assist with spatial recognition, physical therapy evaluation and treat as ordered and needed, and room modification to allow for optimum space for the resident to move about. Further review of the care plan revealed no intervention in place for proper footwear. Interview on 08/18/22 at 10:59 A.M. with Restorative Nurse #36 verified Resident #10's care plan did not address proper footwear and stated proper footwear was usually one of the first interventions implemented. Restorative Nurse #36 updated the resident's care plan on 08/18/22 at 11:05 A.M. 2. Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included transient cerebral ischemic attach, type II diabetes, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chest pain, atherosclerotic heart disease of native coronary artery without angina pectoris, cognitive communication disorder, hyperlipidemia, essential primary hypertension, dementia in other diseases classified elsewhere without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired. Review of the Self-Reported Incidents (SRI) dated 07/14/22 revealed Resident #28 was observed in bed with another resident. The local police department was notified, residents were separated, skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365361 If continuation sheet Page 2 of 4 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 365361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shawnee Manor 2535 Fort Amanda 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 checks and body assessments were completed with no injury, and notifications were completed. Level of Harm - Minimal harm or potential for actual harm Review of the SRI dated 08/01/22 revealed Resident #28 had a cane in the air and another resident reported Resident #28 had hit him on the arm. The residents were separated and assessed. Residents Affected - Few Review of the SRI dated 08/12/22 revealed Resident #28 pushed another resident to the floor. Assessments were completed, no injury occurred, notifications were made, and fifteen minute check in place. Review of Resident #28's undated care plan revealed interventions in place for elopement including redirect exit seeking behaviors as needed, secure unit per physician order, staff will be aware of resident's location at all times, assess for fall risk, and distract resident from wandering by offering pleasant diversion activities, food, conversation, television and books. Further review of the care plan revealed no documentation addressing Resident #28 having other behaviors, including inappropriate and aggressive interactions towards others. Interview on 08/18/22 at 10:18 A.M. with the Administrator verified Resident #28's care plan did not include goals and interventions in place to address Resident #28's behaviors. Review of the facility policy titled, Resident Assessment, revised 11/02/16, revealed the facility will develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must periodically reviewed and revised by a team of qualified persons after each assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365361 If continuation sheet Page 3 of 4 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 365361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shawnee Manor 2535 Fort Amanda 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assessment and Assurance (QAA) sign-in documents and staff interview, the facility failed to ensure all required members attended a QAA meeting quarterly. This had the potential to affected all 82 residents. The facility census was 82. Residents Affected - Many Findings include: Review of the QAA sign-in documents for July 2022 revealed the medical director did not attending the QAA meeting on 07/28/22. The last meeting the medical director attended was on 04/29/22. Interview on 08/18/22 at 2:50 P.M. with the Administrator verified the medical director did not attend QAA meeting on 07/28/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365361 If continuation sheet Page 4 of 4