Health inspection·April 20, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure areas of bruising were appropriately assessed, documented, and monitored. This affected one resident (#21) out of three residents reviewed. The facility census was 32. Residents Affected - Few Findings include: Record review for Resident #21 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, age-related osteoporosis without current fracture, anxiety disorder, insomnia, vascular dementia, type two diabetes mellitus, bipolar disorder, fibromyalgia, and intervertebral disc degeneration. This resident was transferred out to the hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/13/23, revealed this resident had intact cognition as evidenced by a brief interview for mental status (BIMS) assessment score of 15 out of 15. This resident was assessed to require supervision with setup help only for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for personal hygiene. Review of the facility Weekly Skin Assessment, dated 03/30/23, revealed this resident was assessed to have bruises to her bilateral upper extremities, bilateral lower extremities, and upper back related to a fall on 03/12/23. Further record review for this resident revealed no additional documentation of areas of bruising on weekly skin assessments, shower sheets, or in progress notes. Interview with State Tested Nursing Assistant (STNA) #195 on 04/18/23 at 10:39 A.M. revealed Resident #21 had a bruise to her arm, maybe some bruising to her back, and her legs were awful and were covered with a lot of bruises. STNA #195 stated Resident #21 was combative, would not stay in bed, and had other behaviors which likely caused the bruises. Interview with STNA #139 on 04/18/23 at 11:22 A.M. revealed Resident #21 had a lot of bruising. STNA #139 stated the resident became really combative as her disease got worse and would hit the side rails on the bed and flop down hard on the toilet which likely caused the bruises to the residents hips. Interview with the Director Of Nursing (DON) and Licensed Practical Nurse (LPN) #299 on 04/18/23 at 12:03 P.M. revealed they were unaware of Resident #21 having any areas of bruising. Interview with Resident #4 on 04/18/23 at 10:35 A.M. revealed Resident #21 had been her roommate before being sent to the hospital. Resident #4 stated Resident #21 had a huge bruise on the underside of her left arm due to falling and hitting it on the bar on the side of the bed and had multiple bruises everywhere. Resident #4 stated she constantly heard staff talking about Resident #21's bruises while they were providing care. Resident #4 stated Resident #21's son came in to the facility and saw all the residents bruises and Resident #4 informed him they had came from her falling. Interview with STNA #195 on 04/19/23 at 12:10 P.M. revealed Resident #21 had a lot of bruises which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 2 of 3 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 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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 0684 STNA #195 had assumed other staff had already seen and were aware of. Level of Harm - Minimal harm or potential for actual harm Interview with the DON and Administrator on 04/19/23 at 12:35 P.M. verified there was no additional documentation of bruises for Resident #21 other than the documentation on the Weekly Skin assessment dated [DATE]. Residents Affected - Few Telephone interview with Registered Nurse (RN) #401 on 04/19/23 at 10:09 P.M. verified Resident #21 was observed on 03/30/23 to have several bruises to her arms and legs and an area of bruising on her back. RN #401 stated the bruises were yellow and purple and looked older. Review of the facility policy titled Skin Assessment, not dated, revealed policy to perform a full body skin assessment as part of the systematic approach to pressure prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toe, skin assessment will be conducted weekly by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Documentation of skin assessment to include date and time of the assessment, observations, type of wound, measurements, color, type of tissue in wound bed, drainage, odor, pain, if the resident refused the assessment and why, and other information as indicated or appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00141839 and OH00142027. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 3 of 3