Health inspection·November 20, 2018

F 0656 resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365974 If continuation sheet Page 2 of 4 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 365974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Quaker Heights 514 West High Street Waynesville, OH 45068 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure ensure an explanation was documented as to why a resident did not attend their care conference. This affected one (#35) of 24 residents reviewed for care conferences. The census was 62. Findings include: Medical record review for Resident #35 revealed an admission date of 07/24/18. Medical diagnoses included heart failure and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #35 revealed she was cognitively intact. Review of care conference for Resident #35 revealed on 12/06/17 there was no signature on the form for the resident. Further review revealed the resident representative was documented as a no call no show. For this care conference there was social services and a registered nurse at the meeting and the activities director was spoke to before the conference. Review of care conferences for Resident #35 revealed on 03/07/18 there was no signature on the form for the resident. Further review revealed the resident representative was documented as did not show. For this care conference there was social services and a registered nurse at the meeting and the activities director was spoken to before the conference. Review of care conferences for Resident #35 revealed on 05/30/18 there was no signature on the form for the resident. Further review revealed the resident representative was documented as did not show. For this care conference there was social services and a registered nurse at the meeting and the activities director was spoken to before the conference. Review of care conferences for Resident #35 revealed on 09/05/18 there was no signature on the form for the resident. Further review revealed the resident representative was documented as did not show. For this care conference there was social services and a registered nurse at the meeting and the activities director was spoken to before the conference. Interview with Resident #35 on 11/19/18 at 9:04 A.M. revealed she had not had a care conference. Interview with Social Services Designee (SSD) #179 on 11/19/18 at 1:39 P.M. revealed Resident #35 refused the care conferences and the family was a no call no show. She further revealed the resident did not sign the care conference sheets and she didn't have any documentation to prove the resident refused the conference. She stated she spoke to the activities director before the conferences to see if there was anything from activities that needed to be included in the conference. She stated therapy and dietary manager were not at the conferences and the nursing staff would speak for the state tested nursing aide if there was anything that needed to be discussed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365974 If continuation sheet Page 3 of 4 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 365974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Quaker Heights 514 West High Street Waynesville, OH 45068 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review the facility failed to ensure a resident who was dependent on staff for personal hygiene received oral hygiene. This affected one Resident (#34) of 24 reviewed for activities of daily. The census was 62. Findings include: Residents Affected - Few Medical record review for Resident #34 revealed an admission date of 07/24/18. Medical diagnoses included cerebrovascular accident and Non-Alzheimer's Dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact. He was coded on the MDS as total dependence for personal hygiene. At attempt to observe Resident #34 on 11/18/18 at 10:46 A.M. revealed the door to his room was closed. An aide was in the room with him and stated he was receiving patient care. At 11:00 A.M. the resident was observed with yellowish substance on the bottom of his teeth and it was noted he had an odor coming from his mouth. Interview with State Tested Nursing Aide (STNA) #126 on 11/18/18 at 11:05 A.M. revealed she changed Resident #34, shaved, dressed, and washed his face. She verified his teeth were dirty and she did not brush them while providing care at 10:46 A.M. Interview with Resident #34 on 11/18/18 at 2:25 P.M. revealed the staff didn't brush his teeth very often. Review of policy entitled Routine Dental Care dated 04/01/07 revealed each resident will receive routine dental care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365974 If continuation sheet Page 4 of 4