Inspection·July 8, 2021

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, record review, and staff interviews, the facility failed to provide appropriate supervision to a resident while eating that was at high risk for choking. This resulted in actual harm when Resident #11 was left unsupervised alone, in the room to eat and the resident choked on food, requiring the Heimlich Maneuver to be performed. Subsequently the resident developed aspiration pneumonia requiring treatment. The facility failed to provide supervision again for the resident during a meal observation of the resident eating alone in the room. This affected one (#11) of the three residents sampled for assistance with Activities of Daily Living (ADL). The facility census was 48. Findings include: Record review for Resident #11 revealed an admission date of 12/01/16, with the following diagnoses: abnormal posture, kyphosis of the cervicothoracic region (abnormal curvature of the spine at the neck), dysphagia, and muscle wasting and atrophy. This resident had no known allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/24/21, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility and toileting, extensive assistance from one staff member for eating, and was dependent on two staff members for transfers. This resident was assessed to have limited range of motion to both upper extremities. Review of the care plan, dated 12/15/16, revealed this resident had impaired self-feeding related to cerebral palsy. Interventions included all drinks in sippy cups per family request, assure positioned correctly and up to table, dining program daily as tolerated twice a day, encourage/cue/assist resident with meals/eating, feed the resident the first few bites of each meal, and provide physical assist as needed to complete at least 50 percent of the meal. Review of the Speech Therapy Discharge note, dated 07/20/17, revealed this resident should receive supervision during all meals to reduce risk for choking and ensure the resident receives appropriate nutrition. Review of the monthly physician orders for June 2021 revealed the resident was to receive a regular diet. Review of the nurse's progress note, dated 06/11/21 and timed 12:30 P.M., revealed Licensed Practical Nurse (LPN) #149 was walking down the hallway and heard Resident #11 choking. LPN #149 responded immediately and yelled for the aide to come quickly. Upon entering the room Resident #11 was turning purple and was choking. LPN #149 began the Heimlich maneuver and Resident #11 let out a big cry with no food observed to come out of the resident's mouth at the time. Resident #11 was assisted back into her chair, vital signs were obtained, and the physician was notified of the incident. Review of the nurse's progress note, dated 06/11/21 and timed 1:00 P.M., revealed the physician was aware of the choking episode and gave orders for an x-ray to be completed. Review of the results of the chest x-ray for Resident #11, dated 06/11/21, revealed right lung opacities (numerous abnormal white spots of uncertain substance) consistent with aspiration pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365906 If continuation sheet Page 2 of 5 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 365906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monarch Meadows Nursing and Rehabilitation 299 Commerce Dr Seaman, OH 45679 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of the nurses progress notes, dated 06/12/21 and time 3:55 P.M., revealed new orders were received for Resident #11 to begin treatment with Augmentin 500 milligrams (mg) twice a day for ten days and to repeat the two view chest x-ray after completion of antibiotic therapy. Review of the facility General Investigation of Incident, signed by the Director of Nursing (DON) and dated 06/11/21, revealed Resident #11 was eating lunch and the nurse heard her coughing/choking. Upon entering the room, Resident #11 appeared to be choking, Licensed Practical Nurse (LPN) #149 and State Tested Nursing Assistant (STNA) #142 performed the Heimlich maneuver. No food was dislodged from the airway and it appeared to only be liquids. Observation on 07/06/21 at 12:20 P.M., revealed STNA #172 delivered the lunch meal tray to Resident #11 in her room, set up the lunch meal for Resident #11, then left the room to continue delivering lunch meal trays to other residents. Interview with STNA #172 on 07/06/21 at 12:35 P.M., verified Resident #11 was eating her lunch meal in her room without staff members present to supervise. Observation on 07/08/21 at 8:17 A.M., revealed STNA #114 delivered the breakfast meal tray to Resident #11 who was seated at a tray table in the hallway, set up the tray, then left to deliver remaining meal trays without attempting to provide the first few bites of the meal to Resident #11. Interview with STNA #114 on 07/08/21 at 8:25 A.M., verified she had set up the breakfast meal for Resident #11 and had not attempted to feed Resident #11 the first few bites of her meal. STNA #114 stated Resident #11 was to be in the hallway for all meals so she could be supervised by staff since she experienced a choking episode. STNA #114 stated staff did not attempt to feed Resident #11 since she could feed herself. Interview with the Director of Nursing (DON) on 07/08/21 at 10:40 A.M., verified Resident #11 had a care plan in place which included to feed the resident the first few bites of her food. She stated sometimes Resident #11 would not allow staff to do so. The DON verified Resident #11 required supervision during meals prior to the incidence of choking on 06/11/21. The DON stated the nurse was outside the room of Resident #11 with her medication cart when she heard Resident #11 choking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365906 If continuation sheet Page 3 of 5 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 365906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monarch Meadows Nursing and Rehabilitation 299 Commerce Dr Seaman, OH 45679 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, recipe review, policy reviews and staff interviews, the facility failed to appropriately store and prepare food items. This had the potential to affect 48 of 48 residents who resided in the facility and received their meals from the kitchen. Findings include: 1. Observation on 07/06/21 at 11:30 A.M., of Dietary Manager (DM) #135 pureeing the lunch meal revealed ham was placed in the robot coupe canister, water was added to the ham, and the ham and water were blended together. DM #135 then added more water to the mixture and blended them together. DM #135 added powdered thickener to the ham and water mixture and blended it again then poured the mixture into a pan on the steam table. The robot coupe canister was placed in the dishwasher and ran through a cycle but was not allowed to dry before DM #135 added broccoli and water to the canister and began blending them together. The pureed broccoli was placed in a pan on the steam table and DM #135 placed the robot coupe canister in the dishwasher. DM #135 removed the canister from the dishwasher and did not allow it to dry before adding scalloped potatoes to the canister. DM #135 added water to the scalloped potatoes, blended them together, then placed the pureed scalloped potatoes in a pan on the steam table. Interview with DM #135 on 07/06/21 at 11:55 A.M., verified only water and thickener had been added to the foods during preparation of the pureed lunch meal. DM #135 stated recipes were available for the pureed lunch meal although they had not been out to view during preparation of the pureed lunch meal. DM #135 stated the robot coupe canister used to puree the foods for the lunch meal had not been allowed to dry between preparation of different foods due to there only being one canister and not having enough time to allow it to dry completely. Review of the facility recipe for pureed broccoli revealed melted butter should have been added to the broccoli prior to blending. Review of the facility recipe for pureed scalloped potatoes revealed low-sodium chicken base should have been added to the scalloped potatoes while processing them. Review of the facility recipe for pureed ham revealed pineapple juice should be added to the ham and then the ham should be processed. Review of the facility policy titled Mechanical Soft Diets, not dated, revealed it was the responsibility of the Dietary Manager to assure recipes for the pureed diets were available and followed by staff. 2. On 07/06/21 at 9:25 A.M, observation of the walk in freezer revealed no thermometer inside the freezer. On 07/06/21 at 9:30 A.M., observation of the walk in freezer revealed an opened and undated bag of omelets to the air, opened and undated, pirogues and opened and undated bag of opened cinnamon rolls. O Interview with Dietary Manager #135 at the time of the observation verified the food opened, not dated and the freezer had no thermometer. 3. On 07/06/21 at 9:45 A.M., observation of reach in refrigerator #2 revealed no thermometer to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365906 If continuation sheet Page 4 of 5 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 365906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monarch Meadows Nursing and Rehabilitation 299 Commerce Dr Seaman, OH 45679 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 0812 monitor the temperature. Level of Harm - Minimal harm or potential for actual harm Interview with Dietary Manager #135, at the time of the observation verified the lack of thermometer. Residents Affected - Many 4. Observation on 07/08/21 at 8:13 A.M., revealed State Tested Nursing Assistant (STNA) #118 removed the breakfast tray for Resident #29 from the dining cart and took the tray into the residents room where she assisted Resident #29 to consume her breakfast meal. Observation on 07/08/21 at 8:20 A.M., revealed STNA #118 brought the dirty breakfast tray out of the room of Resident #29 and placed it on the top shelf of the dining cart with clean breakfast trays remaining on the cart underneath it. STNA #118 and STNA #114 then proceeded to distribute the remaining clean trays containing the breakfast meal to residents on the hallway. Interview with STNA #118 on 07/08/21 at 8:22 A.M., verified the breakfast tray for Resident #29 was dirty and the tray had been placed back on the dining cart with clean trays underneath it. Review of the facility policy titled Room Meal Tray Service, not dated, revealed soiled trays shall be returned to the cart only when cart is emptied of all undelivered trays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365906 If continuation sheet Page 5 of 5