Inspection·November 6, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medical record review, observation, staff interview, and review of a facility policy, the facility failed to treat a resident with respect and dignity while providing care. This affected one resident (#37) of four residents observed for medication administration. The facility census was 85. Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included Down Syndrome, early onset Alzheimer's disease and profound intellectual disabilities. Review of the resident's quarterly Minimum Data Set assessment, dated 08/28/19, revealed the resident's cognition was severely impaired. Review of the resident's most recent care plan, revised 09/06/19, revealed Resident #37 had a communication deficit related to impaired cognition and did not speak. Interventions included to talk with the resident while providing care and converse about current events and to explain to the resident the care you were going to perform, prior to performing it, Observation on 11/04/19 from 7:30 A.M. through 8:05 A.M. revealed Licensed Practical Nurse (LPN) #275 gathered the resident's tube feeding and prepared Resident #37's medication to be administered through the resident's gastric tube. LPN #275 entered the resident's room, pulled her blanket down to expose her gastric tube and began administering medication through the tube one at a time. After administering the medication LPN #275 administered the tube feeding into the gastric tube. When the LPN was finished, he prepared a breathing treatment for the resident. LPN #275 grabbed and removed her oxygen mask from her face and replaced it with the mask for the breathing treatment and started the treatment. LPN #275 covered the resident back up and left the room. At no time was LPN #275 observed to speak to the resident nor did he make any attempts to explain what he was going to do with her before he did. Interview on 11/04/19 at 8:06 A.M., LPN #275 confirmed he did not speak to Resident #37 at no point while in the resident's room and confirmed he should have spoken to her and let her know what he was going to do. Review of a facility policy titled, Medication Administration; Enteral Tube Medication Administration dated 06/21/19, revealed staff were to explain the procedure and medication to the resident, prior to administering. 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: 365508 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 365508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Welcome Nursing Home 417 South Main Street Oberlin, OH 44074 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)