Inspection·May 9, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on medical record review, review of email correspondences, staff interview and review of facility policy, the facility failed to follow their policy to prevent neglect when staff failed to provide repositioning and incontinence care for more than eight hours for a resident who required extensive assistance from staff. This affected one (Resident #11) of three residents reviewed for care. The facility census was 53. Findings include: Review of the medical record for Resident #11 revealed an admission date of 03/26/21 with diagnoses of dementia, anxiety, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/04/23, revealed Resident #11's cognition was not assessed, though she exhibited no signs of mental status change, inattention, disorganized thinking, or altered level of consciousness. Resident #11 required extensive assistance of two people for bed mobility and toileting. She was frequently incontinent of bowel and bladder and required partial/moderate assistance to roll to the left and right. Review of the current plan of care (POC) revealed an activity of daily living (ADL) self care performance deficit related to activity intolerance. Interventions included to provide extensive assistance of one to two staff for toileting and turning. Review of the current POC revealed the resident had a potential for pressure ulcer and skin impairment development related to immobility and incontinence. Interventions included frequent repositioning and educate caregivers to causes of skin breakdown including repositioning requirements. Review of the POC Response History identified a task to check and change Resident #11 every two hours and as needed. This form revealed on 05/01/23 the last time this task was completed for Resident #11 was at 9:26 P.M. The task was not documented as being completed again until 05/02/23 at 6:00 A.M. Review of an email correspondence between Resident #11's daughter and the Administrator, dated 05/02/23, revealed the resident's daughter reported the resident was put to bed on 05/01/23 at 7:12 P.M. and was not checked on again until 05/02/23 a little past 8:00 A.M. The daughter expressed her concern and asked for the Administrator to follow up with her. Review of an email correspondence between the Administrator and Resident #11's daughter on 05/02/23 revealed the Administrator responded he had checked the call light logs and staff had been in (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: 366144 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 05/09/2023 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)