Health inspection·June 9, 2022

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** Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect. This affected two (Residents #30 and #6) of two residents reviewed. The facility census was 35. Findings include: 1. Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/16/22, revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance for activities of daily living. Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. Resident #30 required set up help of one for meals. Resident had no verbal or physical behaviors exhibited including rejection of care. Resident #30's hearing was adequate and vision moderately impaired. Resident wore corrective lenses. Review of the care plan, dated 04/14/22, revealed resident was dependent on staff for meeting emotional, intellectual, physical and social needs related to disease process, diagnosed with dementia. Interventions included all staff to converse with resident while providing care. Resident has behavior problems which included tearful bouts, fluctuating in mood related to dementia. Interventions included to explain all procedures to the resident before starting and allow resident adequate time to adjust to changes. During observation on 06/07/22 at 8:36 A.M., Resident #30 was sitting in the facility lounge, in her wheelchair, sleeping. Resident #30 had a clothing protector on. State Tested Nursing Assistant (STNA) #846 walked up behind Resident #30, quickly removed the clothing protector from behind and walked away without addressing the resident. Resident #30 startled, woke up, began holding her arms in the air crying, no, no. Licensed Practical Nurse (LPN) #822 was present during the observation, verified this was not a correct approach by STNA #846. During interview on 06/07/22 at 8:38 A.M., STNA #846 confirmed the above observation. STNA #846 stated Resident #30 would scream anyway and the best approach is to sneak up on her. During interview on 06/07/22 at 2:50 P.M., the Director of Nursing (DON) confirmed STNA 846's approach was not appropriate and stated sometimes Resident #30 does yell with hands on care. (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 6 Event ID: 366012 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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)