Health inspection·September 21, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, Self-Reported Incident (SRI) review, employee disciplinary review, staff interview, resident interview, in-service review and policy review, the facility failed to ensure a resident was free from verbal and physical abuse by a staff member. This affected one (#56) of three resident reviewed for potential abuse. The facility census was 56. Findings include: Review of medical record for Resident #56 revealed admission date of 11/17/22, with diagnoses including Parkinson's disease, stress incontinence, urinary incontinence, and difficulty in walking. Review of the Minimum Data Set (MDS) assessment, dated 07/08/23 revealed with a brief interview mental status (BIMS) score of 15 indicating cognitively intact. The resident required extensive two assist of one person for toileting and walk in room. The resident was frequently incontinent of urine and always continent of bowel. Review of the care plan relative to incontinence revealed Resident #56 has stress bladder incontinence related to activity intolerance, disease process, impaired mobility, medication side effects, and physical limitations. Interventions included: Check resident every 2 hours, upon request, and as needed, and as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. Resident requires extensive assistance of one staff participation for toilet use and for bed mobility, resident requires extensive assist of one staff participation. Interview on 09/21/23 at 12:40 P.M., with Resident #56 revealed she had never had any problem other than with the State Tested Nurse Assistant (STNA) #300. Resident #56 stated she has not seen STNA #300 since she reported her for the way she treated her. Resident #56 restated what she had told the facility about how STNA #300 acted, treated her and she was happy with that. Resident #56 stated the staff here are good and not sure why this one STNA was rushing around and grumpy. Review of Self-Reported Incident (SRI) # 238881, revealed STNA #244 reported on 09/06/23, that Resident #56 stated a blonde-haired aide was nasty, mean, and rough with her. She had pushed her into the bathroom with her arm and she felt very unsafe, the aide did not use a gait belt. The aide yelled at her telling her to stand up and did not help her. STNA #300244 also reported the resident had bruising to her arm. Upon assessing the resident's skin, two bruises were evident on either side of the resident's left arm/elbow. The location and size of the bruises indicated that they could have (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 3 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 09/21/2023 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)