Health inspection·January 16, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure care plans were accurate and current. This affected two residents, (#10 and #20) out of five residents reviewed for care plans. The current census was 53. Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of right humerus, unspecified intellectual disabilities, depression, anxiety, insomnia, and pain. Review of Resident #10's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had impaired cognition. Review of the psychiatric diagnostic evaluation dated 02/17/23 revealed the Psychiatric Licensed Social Worker (PLSW) documented Resident #10 had a history of past trauma involving the murder of her brother, abuse by her parent, and abuse by her partner. Per the evaluation ongoing counseling and evaluation from a psychiatrist for medication management was recommended. Review of Resident #10's care plans dated, 01/13/25, revealed a focus added to the care plans for of history of traumatic experiences. No care plan for trauma was added the the resident's care from 11/29/22 to 01/13/25. Interview on 01/15/24 at 3:33 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #10 had reported her past trauma to the social worker sometime during 12/2024. Per the Administrator upon the report the care plan for trauma was not initiated until 01/13/25. Per the DON, Resident #10 did not report the type of trauma and/or any triggers of trauma to anyone prior to 12/2024 per her knowledge. Interview on 01/16/24 at 8:33 A.M. with Social Worker (SW) #380 revealed on 01/03/25 Resident #10 reported to the social worker she had a past trauma of abuse from her family, including her ex-husband. SW #380 stated she reported the trauma to the Administrator but did not document the report. SW #380 denied knowledge of the psychiatric evaluation dated 02/17/23, and stated she was not made aware of the details regarding the resident's trauma until 01/03/25. 2. Review of the medical record for Resident #20 revealed the resident admitted to the facility on [DATE]. Diagnoses included multiple rib fractures post fall, urinary retention, heart disease, and (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 3 Event ID: 365405 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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)