Health inspection·August 12, 2019

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible. This affected three (Residents #45, #79 and #98) of 104 residents reviewed for call light placement. Residents Affected - Few Findings include: 1. Record review revealed Resident #45 was readmitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia with behavioral disturbance, and atherosclerotic heart disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance of activities of daily living. Review of Resident #45's care plan dated 05/05/18 revealed interventions state that call light should be within reach and resident is encourage to ask and use call light for assistance. During observation of Resident #45 on 08/05/19 at 10:01 A.M., she was sitting in her wheelchair located near the end of the bed and her call light was located at the head of the bed. Resident #45 stated that she could not reach the call light. This was verified at the time of observation by State Tested Nursing Assistant (STNA) #72. During observation of Resident #45 on 08/07/19 at 7:48 A.M., she was sitting in her wheelchair located near the end of the bed and her call light was located at the head of the bed. Resident #45 stated that she could not reach the call light. This was verified at the time of observation by Licensed Practical Nurse (LPN) #53. 2. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder and dementia without behavioral disturbances. Review of the most recent MDS assessment dated [DATE] revealed Resident #79 was moderately cognitively impaired and required extensive assistance for activities of daily living. Review of Resident #79's care plan dated 09/09/16 revealed interventions state that call light should be within reach and resident is encourage to ask and use call light for assistance. During observation on 08/07/19 at 8:00 A.M. Resident #79 was sitting in her wheelchair next to the bed. Resident #79's call light was inside her night stand drawer and was out of her reach. This was verified at the time of observation by Licensed Practical Nurse (LPN) #53. 3. Review of the medical record for Resident #98 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral palsy, anxiety disorder, and peripheral vascular disease. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #98 was moderately cognitively impaired and required extensive assistance for activities of daily living. Review of Resident #98's care plan dated 08/19/18 revealed interventions state that call light should be within reach and resident is encourage to ask and use call light for assistance. During observation on 08/07/19 at 8:15 A.M., Resident #98 was sitting in her wheelchair next to the foot of the bed. Resident #98's call light was wrapped around her bed rail and was out of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0558 reach. This was verified at the time of observation by State Tested Nursing Assistant (STNA) #68 Level of Harm - Minimal harm or potential for actual harm Interview with Assistant Director of Nursing #48 on 08/07/18 at 3:41 P.M. revealed that employees are told during orientation that call lights must be within reach, call lights should be answered as quickly as possible and there is a call light panel and the desk which will tell a person the room number and the amount of time the call light was on. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure resident's laboratory orders were completed as ordered. This affected one of one resident (#60) reviewed for laboratory services. The facility census was 104 residents. Residents Affected - Few Findings include: Review of Resident #60's medical record revealed diagnoses including diabetes. The resident had a physician order dated 02/11/19 for a Glycohemoglobin-HGBA1C laboratory test (a blood test that checks the amount of glucose bound to the hemoglobin in the red blood cells) to be performed every three months for diabetes monitoring. Review of the medical record revealed the HGB A1C was completed on 02/11/19. There was no evidence the test was performed in May 2019 as ordered. Interview with 08/08/19 08:36 A.M. LPN #21 verified the only HGB A1C was drawn on 02/11/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to thoroughly check the Nurse Aide Registry prior to hiring a nurse aide. This affected one (STNA #100) of five personnel files reviewed. This had the potential to affect all 102 residents who resided at the facility. Residents Affected - Many Findings include: Review of the personnel file for STNA #100, revealed date of hire 05/15/19; last day worked 08/02/19; and termination on 08/06/19 for no call no show. During interview on 08/12/19 at 10:13 A.M., Scheduling Resources (SR) #550 reported when searching the Ohio Nurse Aide Registry, the employee's first and last name along with the last four digits of the social security number are used. SR #550 stated she missed entering the last four digits of STNA #100 into the Nursing Aide Registry for verification. Observation on 08/12/19 at 11:05 A.M. of the Nurse's Aide Registry search with (SR) #550 revealed STNA #100's first and last name only yielded a registry number and good standing; however when STNA #100's name AND last four digits of the social security number was searched in the Ohio Nurse Aide Registry, it yielded no results. STNA #100 had the same first and last name as another STNA. The other STNA was on the registry in good standing; STNA #100 was actually not on the registry at all. Review of facility policy titled Ohio New Hire Policy, undated, revealed hiring manager reviews application and performs nurse aide registry check on all potential candidates prior to scheduling interview. This deficiency substantiates Complaint Number 106275. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 5 of 5