Health inspection·August 8, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #15's medical record revealed an admission date of 11/01/21. Diagnoses included dementia with behavioral disturbance, schizoaffective disorder, and Parkinson's disease. Review of Resident #15's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #15 was severely cognitively impaired. Resident #15 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #15 displayed no behaviors during the review period. Review of Resident #15's care plan revised 07/30/22 revealed supports and interventions for behavior problems related to dementia, Parkinson's disease, resistance to care, self-care deficit including two staff assist for dressing, and the resident was at risk for falls. Observation on 08/01/22 at 9:57 A.M. of Resident #15 found him sitting in a recliner in the common area with his feet elevated on the foot rest of the recliner. Resident #15 was wearing grip socks and his first and last name were visible on both socks. Observation on 08/01/22 at 10:02 A.M. found a family member of another resident walking near Resident #15. The family member was observed looking down at Resident #15's socks which had his first and last name visible. Observation on 08/01/22 at 10:30 A.M. found Resident #15 continued to be seated in a recliner in the common area with his feet up on the foot rest of the recliner and his first and last name visible. Interview on 08/01/22 at 10:33 A.M. with Licensed Practical Nurse (LPN) #537 verified Resident #15's was in the common area and his first and last name was visible on his socks. LPN #537 reported Resident #15 did not walk well when he wore shoes so he only wore the nonskid grip socks he was currently wearing. LPN #537 stated Resident #15's name should be on the inside of the grip sock or on an area not visible to visitors. LPN #537 stated she would get Resident #15 a different pair. Review of the facility policy titled, Dignity, revised February 2021 revealed staff were to promote, maintain, and protect resident privacy. Staff were expected to promote dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 2 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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** Residents Affected - Few Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to assist a female resident with shaving facial hair. This affected one (Resident #2) of three residents reviewed for activities of daily living. The facility census was 39. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 10/13/21. Diagnoses included dementia with behavioral disturbance, paranoid schizophrenia, cognitive communication deficit, and adult failure to thrive. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating Resident #2 was severely cognitively impaired. Resident #2 required supervision, set up only with personal hygiene. Resident #2 displayed no behaviors during the review period. Review of Resident #2's care plan revised 08/01/22 revealed the resident was at risk for impaired activities of daily living function due to cognition. Resident #2 was able to complete personal hygiene tasks independently, but was noted to require increased assistance at time when she was feeling weak, fagitued, or had increased pain. Review of Resident #2's progress notes revealed Resident #2 accepted a shower on 07/12/22 and 07/17/22. On 07/17/22 it was noted Resident #2's hair was braided and nail and foot care was provided. Review of Resident #2's State Tested Nursing Assistant (STNA) Tasks for the last 30 days revealed Resident #2 also received showers on 07/04/22 and 07/09/22. Resident #2 required physical assistance with bathing. Review of Resident #2's STNA Task for personal hygiene revealed Resident #2 ranged from needing limited assistance to being independent with her personal hygiene tasks. Personal Hygiene tasks were to include hair combing, brushing teeth, shaving, applying makeup, and washing and drying face and hands. The specific tasks completed each day were not listed. Observation on 08/01/22 at 10:20 A.M. found Resident #2 walking down the hallway. Resident #2 was noted to have facial hair on her upper lip and chin. Interview on 08/01/22 at 10:38 A.M. with Resident #2 revealed she was happy with the showers she was getting but had not been getting her facial hair taken care of. Resident #2 reported she used to be able to take care of it herself, but she wasn't able to do it any more. Resident #2 stated she wanted it done and she was told by someone they would take care of it on her shower day but it wasn't done. Observation on 08/01/22 at 11:39 A.M. of Resident #2 found State Tested Nursing Assistant (STNA) #512 talking with Resident #2 about getting a shower and if she wanted her hair braided. Resident #2 stated she wanted two braids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 3 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/02/22 at 8:14 A.M. of Resident #2 found her seated at the dining table in the common area on her hallway eating breakfast. Resident #2's hair was clean and braided. Resident #2 was found to still have significant facial hair on her upper lip and her chin. Observation on 08/02/22 at 1:49 A.M. of Resident #2 found her walking up and down the hallway talking with STNA #512. Resident #2 was noted to still have facial hair on her upper lip and chin. Interview on 08/02/22 at 1:58 P.M. with STNA #512 revealed Resident #2 was able to do most of her own care with set up only. However, Resident #2 required physical assistance with shaving. STNA #512 verified Resident #2's face had not been shaved. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018 revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good grooming and personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 4 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of facility policy, the facility failed to assess, document, measure, and complete accurate assessments for pressure ulcers. This affected one (Resident #245) out of three residents reviewed for pressure ulcers. The facility's census was 39. Residents Affected - Few Findings include: Record review of Resident #245 revealed the resident was admitted to the facility on [DATE]. Resident #245 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses for Resident #245 included COVID-19, chronic kidney disease, obesity, atrial fibrillation, history of falls, stage II pressure ulcer of sacrum, pressure induced deep tissue damage to right heel, altered mental status, and dysphagia. Review of Resident #245's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition with one unstageable pressure ulcer and one deep tissue injury. Further review of Resident #245's medical record revealed a baseline care plan had not been initiated. Review of the care plan dated 07/06/22 revealed the care plan did not address skin breakdown or pressure ulcers. The care plan was updated on 07/31/22 with a focus for pressure ulcers and skin impairment. Interventions included administer medications and treatments per order, assess, record, and monitor wound healing progress, measure length, width, and depth where possible, assess and document the status of the wound perimeter, wound bed and healing progress, and report improvements and declines to the doctor. Review of the nursing admission assessment dated [DATE] revealed Resident #245 had the following skin impairments: pressure on coccyx, other (shearing) on right hip, other (shearing) on left hip, other (necrotic) on right heel, other (bruising) on left forearm, other (bruising) on right forearm. No measurements, staging of the pressure ulcer, or description of the wounds were documented in the assessment. Review of Resident #245's skin sweep assessment dated [DATE] revealed the resident was documented as having a pressure ulcer on the right thigh measuring 1 centimeter, (cm) by 1 cm, no depth, no staging noted. Redness on the right thigh. Pressure ulcer on the left thigh measuring 2.5 cm by 3 cm, no depth and no staging noted. Pressure ulcer on the right heel measuring 4.5 cm by 3.5 cm, no depth and no staging noted. Blister on the right hip 0.5 cm by 0.5 cm, no depth or staging noted. Redness on the coccyx, no measurements noted. Redness on the left heel. Bruising on bilateral arms and redness in the abdominal folds. Review of the nursing re-admission assessment dated [DATE] revealed the skin assessment portion of the assessment had not been completed. Review of the skin sweep assessment dated [DATE] revealed the resident was documented as having a blister on the right hip. Pressure ulcer on the coccyx, no measurements or staging noted. Pressure ulcers on right and left buttocks with no measurements or staging noted. Pressure ulcer on the right heel, no measurements or staging noted. Scratches on left thigh and right thigh. Pressure ulcer on the right thigh. Bruising on bilateral arms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 5 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #245's wound physician documentation dated 07/19/22 revealed the physician documented the resident as having an unstageable pressure ulcer with necrosis to the coccyx measuring 2 cm by 2 cm with no depth. Per the note, the resident had moderate serous drainage and 100% slough, the wound was noted as healing. Resident #245 had a stage II pressure ulcer on the left thigh measuring 0.5 cm by 0.5 cm by 0.1 cm depth, the wound had no drainage and was noted as healing. A full thickness wound on the right thigh measuring 0.5 cm by 0.5 cm by 0.1 cm was noted as healing. No other wounds were noted in the wound physician documentation. Review of the skin sweep assessment dated [DATE] revealed Resident #245 was documented as having a pressure ulcer on the coccyx, no measurements or staging was noted. Pressure ulcers to right and left gluteal folds, no measurements or staging noted. Pressure ulcer to the left hip, no measurements or staging noted. Redness to abdominal folds, and redness to the groin. Review of Resident #245's wound physician documentation dated 07/26 22 revealed the physician documented the resident as having an unstageable pressure ulcer with necrosis to the coccyx measuring 2 cm by 1.8 cm with no depth. Per the note there was moderate drainage and 80% slough and the wound was improving and healing. The stage II pressure ulcer on the left thigh had resolved. The right thigh wound was measured at 0.5 cm by 0.5 cm by 0.1 cm and noted as improved and healing. An unstageable deep tissue injury to the right heel measuring 0.8 cm by 1 cm with non-measurable depth was noted as healing. Review of the skin sweep assessment dated [DATE] revealed Resident #245 was documented as having a pressure ulcer on the coccyx, no measurement or staging noted. Rash on gluteal folds and groin. Redness on abdominal folds. Pressure ulcer on the left hip, no measurements or staging noted. Blister on the right hip. Pressure ulcer on the right heel, no measurements or staging noted. Pressure ulcer on the left heel, no measurements or staging noted. Review of the skin sweep assessment dated [DATE] revealed Resident #245 was documented as having a pressure ulcer to the coccyx measuring 2 cm by 0.5 cm by 0.5 cm, no staging was documented. Redness under bilateral breasts. Scab wound on right heel measuring 1 cm by 0.8 cm with no depth, unstageable. Redness on the right hip, right thigh and abdominal folds. Interview on 08/03/22 at 11:40 A.M. with the Wound Physician revealed the physician had treated Resident #245's wounds and stated due to her current immobility and co-morbidities, the wounds were unavoidable. Per the physician he was to be updated by the nursing staff of the current stages and measurements of the wounds prior to his assessment of the wounds. Observation on 08/03/22 at 1:45 P.M. of the wounds and dressing changes for Resident #245 with Licensed Practical Nurse (LPN) #543 and LPN #537 revealed Resident #245 had three dressings dated 08/03/22 applied prior to the observed dressing change. Bandages were noted on the right hip, the right heel, and the coccyx. LPN #537 reviewed all physician ordered dressing changes and prepared the treatment supplies per physician orders. LPN #537, following infection control procedures, removed all old dressings and assessed the resident's wounds. On Resident #245's right hip, the wound appeared to be healed with no open areas and no redness noted. On the right heel, a black small scab was noted with no drainage. LPN #537 measured the right heel to be 1.2 cm by 0.8 cm. The coccyx wound was noted to be red, no drainage, no slough, no necrosis. Per the nurses, the wound appeared to be a stage II, as previously noted in the resident's wound documentation. The nurses assessed the rest of the resident's documented wounds with the surveyor observing. No wounds or skin breakdown on the left hip, bilateral thighs, under the bilateral breasts, or the left heel were observed. Redness on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 6 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 0686 abdominal folds appeared to be light in color and the groin appeared to have no redness or wounds noted. Level of Harm - Minimal harm or potential for actual harm Interviews on 08/03/22 at 1:45 P.M. with LPN #543 and LPN #537 verified nurses were to measure all wounds for comparison. All wounds were to be monitored and the nurse was to report any changes to the wound physician. The nurses admitted when documenting, they often did not complete measurements or staging portions of the assessments. Residents Affected - Few Interview on 08/03/22 at 3:45 P.M. with the Director of Nursing (DON) and the Administrator verified the weekly skin sweeps were not being completed per policy. The Administrator verified there had been no baseline care plan or current care plan initiated for Resident #245 until 07/31/22 reflecting skin breakdown or pressure ulcers. The DON stated upon admission, the nurse was to assess the resident's skin, measure any wounds, and report all skin issues to the physician. The DON verified there was no skin assessment completed on 07/14/22 and the admission assessment on 07/06/22 was inaccurate with no wound measurements, staging, or descriptions of the resident's wounds. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown Clinical Protocol, dated 04/2018 revealed the nurse shall describe and document/report a full assessment of the pressure sore including stage, length, width, and depth, presence of drainage and necrotic tissue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 7 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of manufacturers recommendations, and review of facility policy, the facility failed to ensure medications were administered without errors. This resulted in two medication errors out of 27 medication opportunities or a 7.4 percent (%) medication error rate. This affected one (Resident #28) out of eight residents observed for medication administration. Facility census was 39. Residents Affected - Few Findings include: Observation on 08/03/22 at 4:15 P.M. revealed Licensed Practical Nurse (LPN) #575 was observed preparing medication to be administered to Resident #28. LPN #575 removed a Aspart Tempo insulin pen from the medication cart and dialed 15 units on the pen and placed a clean needle on the end of the pen. LPN #575 removed a Basaglar Kwikpen (insulin pen) from the medication cart and dialed 33 units into the pen and placed a clean needle on the end of the pen. She took both insulin pens into the resident's room and injected the insulin from both insulin pens into the resident's lower abdomen. Interview on 8/03/22 at 4:25 P.M. LPN #575 verified she did not prime the needles with 2 units of insulin before dialing in the dosage for insulin, prior to administering the insulin to Resident #28. LPN #575 stated she didn't think she had to prime the needles on the insulin pen. Review of the manufacture's instructions for, Tempo Insulin Pen, revealed to prime the pen, turn the knob to select 2 units. Hold the pen pointing up, tap the cartridge holder to collect the bubble to the top, and hold the dose knob in counting to 5 slowly. If you do not see insulin in the tip repeat priming steps. Review of the facility's undated policy titled, Insulin Pen, revealed insulin pens are to primed prior to each use to avoid collection of air in the insulin reservoir. To prime the pen, dial 2 units by turning the dose selector clockwise. With the needle pointing up push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If no insulin appears on the tip of the needle repeat the priming process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 8 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of manufacturers recommendations, and review of facility policy, the facility failed to ensure staff primed an insulin pen prior to the administration of insulin, resulting in significant medication errors. This affected one (Resident #28) out of eight residents observed for medication administration. Facility census was 39. Residents Affected - Few Findings include: Observation on 08/03/22 at 4:15 P.M. revealed Licensed Practical Nurse (LPN) #575 was observed preparing medication to be administered to Resident #28. LPN #575 removed a Aspart Tempo insulin pen from the medication cart and dialed 15 units on the pen and placed a clean needle on the end of the pen. LPN #575 removed a Basaglar Kwikpen (insulin pen) from the medication cart and dialed 33 units into the pen and placed a clean needle on the end of the pen. She took both insulin pens into the resident's room and injected the insulin from both insulin pens into the resident's lower abdomen. Interview on 8/03/22 at 4:25 P.M. LPN #575 verified she did not prime the needles with 2 units of insulin before dialing in the dosage for insulin, prior to administering the insulin to Resident #28. LPN #575 stated she didn't think she had to prime the needles on the insulin pen. Review of the manufacture's instructions for, Tempo Insulin Pen, revealed to prime the pen, turn the knob to select 2 units. Hold the pen pointing up, tap the cartridge holder to collect the bubble to the top, and hold the dose knob in counting to 5 slowly. If you do not see insulin in the tip repeat priming steps. Review of the facility's undated policy titled, Insulin Pen, revealed insulin pens are to primed prior to each use to avoid collection of air in the insulin reservoir. To prime the pen, dial 2 units by turning the dose selector clockwise. With the needle pointing up push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If no insulin appears on the tip of the needle repeat the priming process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 9 of 10 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 366144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to complete labs as ordered. This affected one (Resident #25) out of five residents reviewed for lab completion. The facility census was 39. Findings include: Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure, vascular dementia, dysphasia, paranoid personality, anxiety, psychotic with delusions, essential hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has short and long term memory loss. The resident displayed verbal and physical behaviors one to three days of the assessment period and received antipsychotic, antidepressant, and antianxiety medications. Review of the plan of care updated 07/20/22 revealed Resident #25 was receiving psychotropic medications for psychosis with delusions, anxiety and depression. The interventions included monitoring laboratory test results as ordered by the physician. Review of the monthly physician orders revealed an order initiated on 09/13/17 to draw laboratory tests for lipids (amount of fat molecules in the blood), SGOT (liver enzyme), and SPGT (liver enzyme) annually in November. Further review of Resident #26's medical record revealed lab reports for lipids, SGOT, and SGPT completed on 11/11/19. There were no other lab reports for lipids, SGOT, or SGPT for 2020 or 2021. Interview on 08/03/22 at 2:00 P.M. the Administrator verified there were no lipid, SGOT, or SGPT lab results for 2020 and 2021 for Resident #26. The Administrator verified the laboratory tests had not been obtained. Review of the policy, Lab and Diagnostic Test Results-Clinical Protocol, dated 11/18 revealed staff would process test requisitions and arrange for laboratory tests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 10 of 10