Inspection·April 15, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on medical record review, staff interview, review of facility census, review of the facility self-reported incidents (SRIs), review of facility investigations, and policy review, the facility failed to ensure residents were free from verbal abuse and mistreatment. This affected one (#32) of two residents reviewed for abuse and had the possibility to affect 31 (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) residents residing on the hallway. The facility census was 53. Findings include: Review of the SRI dated 03/11/24, revealed State Tested Nurse Assistant (STNA) #101 left a note for the Director of Nursing (DON) indicating a concern about STNA #100's reaction to Resident #32's behaviors. STNA #101 had witnessed STNA #100 holding down Resident #32's arms/wrists and placed a paper towel over his mouth after Resident #32 had attempted to spit on her. STNA #101 reportedly intervened and instructed STNA #100 to leave the room and STNA #101 would finish the care to Resident #32. Review of the medical record of Resident #32 revealed an admission date of 11/24/23. Diagnoses include syncope and collapse, unspecified dementia, and unspecified psychosis. Review of the minimum data set assessment dated [DATE] revealed Resident #32 to have severe cognition impairment. Review of the skin assessment completed on Resident #32 dated 03/11/24 revealed no skin impairments or discolorations. Review of a handwritten report dated 03/09/24 by Licensed Practical Nurse (LPN) #102 revealed. I have continued concerns about the way she speaks with residents. Another STNA came to me with concerns as well. (I did not witness the incident.) I do notice the residents seem to have increased behaviors when she is on duty, and I have had an increase in residents complaining about her attitude. I have attached a statement from STNA #101, who witnessed an incident today. (A note on this form read Nurses, if you are having problems with nursing assistants on the floor that you are in charge of and need assistance with correction of performance, or for any other reason needing my assistance. Please fill out the bottom portion of this form.) Review of a hand-written note dated 03/09/24 signed by STNA #101 revealed While toileting Resident #32 with STNA #100, Resident #32 began to pull up his pants while STNA #101 was attempting to change them because they were soiled. STNA #101 was trying to remind Resident #32, that his pants were soiled and that they would need to be changed. STNA #101 attempted to pull down Resident #32's pants again, when Resident #32 tried to hit STNA #101 in the face with medium force. STNA #100 then yelled (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 04/15/2024 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)