Health inspection·October 18, 2018

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** 2. Resident #30 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, Alzheimer's dementia, anxiety, depression, macular degeneration, osteoarthritis and low back pain. A review of Resident #30's annual Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment. The MDS assessment indicated Resident #30 needed extensive assistance of one staff member for locomotion on and off the nursing unit and the extensive assistance of two staff members for transfers. An observation of Resident #30 on 10/17/18 at 9:20 A.M. indicated Resident #30 was seated in front of the television in a wheelchair. Resident #30 was calling out to the staff requesting assistance to go to her room. Several staff members were walking in the hallway and in the common room and ignored Resident #30. At the time of the observation Licensed Practical Nurse (LPN) #6 was administering medications to Resident #5. Resident #5 was seated directly behind Resident #30. Resident #30 continued to ask for help to go to bed. LPN #6 did not respond or acknowledge Resident #30 until Resident #30 pushed back her wheelchair and bumped in to LPN #6's leg. LPN #6 then responded she could not go to her room right now and stated Okay, Kiddo?. An interview with LPN #6 upon completion of the medication administration to Resident #5 verified she had addressed Resident #30 as Kiddo and verified the above observation. A review of the facility policy and procedure titled Resident Rights and Facility Responsibilities dated 11/28/16. The policy indicated the facility would abide by all resident rights and to communicate theses right to the residents and designated representative. Nursing facility residents are granted specific rights under Federal law and indicated a duplication of the Federal regulation for reference. The facility duplicated Federal regulations and indicated item (e) Respect and Dignity: The resident had the right to be treated with respect and dignity. Based on observation, record review, policy review and interview, the facility failed to ensure Resident #58 had a dignified dining experience and failed to ensure Resident #30 was treated with respect while sitting in a common area. This affected one (Resident #58) of 29 residents who ate in the second-floor dining room and one (Resident #30) of three residents reviewed for dignity. The facility census was 78. Findings include: 1. Record review of Resident #58 indicated an admission date of 09/18/18 with diagnoses of dementia with behavioral disturbances and cognitive communication deficit. Review of the 09/25/18 Minimum Data Set (MDS) 3.0 admission assessment indicated Resident #58 was severely cognitively-impaired, needed set-up help with her meal and supervision with eating. Review of the 09/27/18 care plan indicated (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 5 Event ID: 365937 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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)