Health inspection·November 7, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility reported incident review, and interview, the facility failed to complete a thorough investigation for an allegation of physical abuse. This affected one resident (#75) of three residents reviewed for allegations of abuse. The facility census was 36. Residents Affected - Few Findings included: Closed record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, chronic systolic congestive heart failure, dysphagia, anemia, panic disorder, and gastro-esophageal reflux disease. Review of minimum data set assessment collected on 04/04/23 revealed Resident #75 had mild- impaired cognition and did not have behaviors related to refusing care. Review of transfer and discharge records revealed Resident #75 transferred to the hospital on [DATE]. Review of a facility reported incident completed on 04/03/23 revealed Resident #75's representative spoke with the administrator regarding an allegation of staff forcing her to take a shower. The facility did start an immediate report to appropriate agencies regarding the alleged incident, but the facility did not provide evidence of interviews with Resident #75, like residents, or staff members and the investigation did not include evidence of a skin check or resident assessment being completed. Interview on 11/07/23 at 2:05 P.M. with the Administrator confirmed there were no other records regarding the investigation to review. Review of a policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source revealed the facility should interview the resident, the accused, and all witnesses including anyone who worked directly with the resident, came into contact with the resident, or heard or saw the incident occur. After each interview, the interviewee should be allowed to review the statement collected and sign to prove the documentation is an accurate reflection of their view. Policy also stated the facility should review the resident records. This deficiency is cited as an incidental finding to Complaint Number OH00143598. Page 1 of 2 365742 365742 11/07/2023 National Church Residences Bristol Village 444 Cherry St Waverly, OH 45690

F 0692 Provide enough food/fluids to maintain a resident's health. 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 nutritional interventions were provided to residents in a timely manner. This affected one resident (#74) of three residents reviewed for nutrition services. The facility census was 36. Residents Affected - Few Findings included: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure, chronic kidney disease stage 3, anemia, gastro-esophageal reflux disease, and atrial fibrillation. Review of a minimum data set (MDS) assessment collected on 11/02/22 revealed Resident #74 had mildly impaired cognition, no behaviors, required set up or clean up assistance with meals, and was receiving a therapeutic diet. Review of orders revealed Resident #74 had an order for a no added salt diet on 10/27/22 and had received an order for Ensure Plus twice a day on 11/22/22. Review of medication administration record (MAR) for November and December 2022 revealed Resident #74 did not receive first administration of Ensure Plus until 12/01/22. Interview on 11/07/23 at 2:02 P.M. with the Director of Nursing (DON) revealed the dietician had made a recommendation for Ensure Plus on 11/22/22, however the physician was out of town and the order was not signed until 12/01/22. The DON stated the facility did have a nurse practitioner to cover for emergent services while the physician was unavailable but she would not sign certain orders such as nutrition recommendations. The DON stated she did not feel this was sufficient and she did not believe the facility had a policy related to physician services. This deficiency represents non-compliance investigated under Complaint Number OH00143598. 365742 Page 2 of 2