Inspection·November 18, 2024

F 0584 Level of Harm - Potential for minimal harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff interview, and review of facility policy, the facility failed to ensure over head paging was used only in case of emergency. This had the potential to to affect all residents in the facility. The facility census was 57. Findings include: Observation on 11/12/24 at approximately 11:00 A.M. found an overhead paging system being utilized requesting maintenance staff to go to the second floor. Observation on 11/18/24 at 9:44 A.M. found the overhead paging system loudly playing what sounded like a phone being on hold. The sound grew increasingly louder. Interview on 11/18/24 at 9:47 A.M. with Administration Staff (AS) #436 verified the overhead paging system was loudly projecting a telephone on hold. Review of the facility policy titled, Overhead Paging Policy, dated 05/29/13 revealed overhead paging would only be allowed in case of an emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 2 of 20 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 11/18/2024 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy for care plans, and staff interview, the facility failed to have a complete care plan relating to a pressure ulcer. This affected one (Resident #34) out of two residents reviewed for pressure ulcer care plans. The current census is 57. Findings include: Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #34 include dementia with Lewy bodies, diabetes type two, atrial fibrillation, and congestive heart failure. Review of Resident #34's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and had no pressure ulcers. Review of Resident #34's MDS significant change assessment dated [DATE] revealed the resident was documented as having one stage three pressure ulcer which was unhealed. Review of Resident #34's care plans dated 06/19/24 revealed there was no focus addressing the care and treatment of Resident #34's pressure ulcer to the coccyx on the baseline care plans. Per the care plans dating from 06/19/24 to 11/11/24 revealed no focus or interventions were noted in the care plans for the stage three pressure ulcer. Further review of Resident #34's care plans updated on 11/12/24, revealed the care plan was revised to include the pressure ulcer focus and interventions. Interview on 11/13/24 at 9:24 A.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) verified the care plan was not revised until 11/12/24 for the stage 3 pressure ulcer. Review of the facility policy titled, 'Care Plans', dated 04/2022 revealed the facility will develop and implement a care plan for consistent with each resident's conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 3 of 20 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 11/18/2024 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)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to develop a discharge summary which included a recapitulation of stay and the resident's final status. This affected one resident (#58) of one resident reviewed for discharge. The facility census was 57. Findings include: Review of Resident #58's medical record revealed an admission date of 08/14/24 and a discharge date of 09/09/24. Diagnoses included heart disease, dysphagia, cognitive communication, dementia, and syncope and collapse. Review of Resident #58's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating Resident #58 was moderately cognitively impaired. Resident #58 required maximal assistance with eating, bathing, transfers, and parts of dressing. Resident #58 was dependent with toilet use, and parts of dressing. Resident #58 displayed verbal behavioral symptoms directed toward other one to three days during the review period. Review of Resident #58's care plan canceled 09/20/24 revealed supports and interventions for potential for skin impairment, increased nutrition and hydration risk, desire to return home, risk for pain, risk for self-care deficit, dementia, risk for falls, and depression. Review of Resident #58's progress notes revealed on 09/09/24 it was noted Resident #58 was discharging. Resident #58 was provided his current face sheet along with his medication list. It was noted Resident #58 left with his eye drops, inhaler, and the rest of his medications. Further review of Resident #58's medical record found no discharge summary containing a recapitulation of his stay nor his final status regarding care needs. Interview on 11/13/24 at 10:37 A.M. with the Assistant Director of Nursing (ADON) verified a discharge summary with a recapitulation of stay had not been provided to Resident #58's when he was transferred to an assisted living in another community. The ADON reported Resident #58's medication list was given to Resident #58 and the information was documented in the nurse's note. Review of the facility policy titled, Transfer and Discharge, dated 10/24/22 revealed for resident initiated discharges the facility was responsible for completing a discharge summary that included but was not limited to a recap of the resident's stay including diagnoses, course of illness/treatment or therapy, and consultation results, a final summary of the resident's status, reconciliation of medications and a post discharge plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 4 of 20 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 11/18/2024 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)

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 medical record review, observations, resident, staff and Nurse Practitioner (NP) #601 interviews, the facility failed to properly assess and treat pressure ulcers. This affected two (Residents #34 and #56) of two residents reviewed for pressure ulcers. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with Lewy bodies, diabetes type two, atrial fibrillation, and congestive heart failure. Review of Resident #34's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, no open wounds, and had no pressure ulcers. Review of Resident #34's care plans dated 06/19/24 revealed there was no focus areas addressing the care and treatment of Resident #34's pressure ulcer to the coccyx on the baseline care plans. Review of Resident #34's admission skin assessment dated [DATE] revealed the nurse documented an 'open lesion' to the coccyx, measuring 2.5 centimeters (cm) width by 0.3 cm length by 0.3 cm depth. There was no assessment regarding a stage to the area to Resident #34's coccyx. There were no orders for treatment noted in the document. Further review of Resident #34's physician orders dated 06/19/24 to 07/01/24 revealed there were no physician orders for treatment to the wound on the resident's coccyx. Further review of Resident #34's treatment records revealed no documentation there was any treatment provided to the wound on the coccyx or gluteal area from 06/19/24 to 07/01/24. Review of the weekly skin assessment dated [DATE] revealed no changes to the open lesion. There were no additional weekly skin assessments completed. Review of Resident #34's wound assessment documentation dated 07/01/24 revealed Resident #34 had a stage three pressure ulcer to the 'gluteal cleft.' Per the documentation the pressure ulcer was a 'new wound as of 07/01/24' and staged as a stage three pressure ulcer. The wound measured 2 cm width by 0.5 cm length by 0.5 cm depth. Per the wound assessment dated [DATE], the wound was 'improved' and was measured at 2.3 cm length by 0.3 cm width by 0.3 cm depth. Per the wound assessment dated [DATE] the wound was 'worse' and measured 3 cm length by 0.5 cm width by 0.5 cm depth. Further review of the resident's wound documentation dated 08/01/24 to 11/10/24 revealed the wound was being monitored and measured per care plans. Review of Resident #34's physician orders dated 07/02/24 revealed the treatment order to cleanse, pat dry, apply honey and alginate to wound bed on coccyx and cover with border foam dressing, one time a day for wound on coccyx. Review of the wound documentation dated 11/10/24 the gluteal cleft wound was as a stage three pressure ulcer and was measured at 3.0 cm width by 1.5 cm length by 0.5 cm depth. Per the document the wound had 'worsened' and the care was directed to palliative care instead of a goal of healed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 5 of 20 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 11/18/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #34's care plan revealed the care plan was updated on 11/12/24 to reflect the resident's pressure ulcer impairment. Interventions included assess, record, and monitor the pressure ulcer per order. Administer treatments per order. Interview and observation on 11/13/24 at 8:38 A.M. of Resident #34's coccyx wound with Assistant Director of Nursing (ADON) during a dressing change, revealed Resident #34's wound appeared to be a stage three pressure ulcer. Per the ADON, the Resident #34's pressure ulcer was present on admission. The ADON verified the pressure ulcer had been staged on 07/01/24 by the NP #601 who was the provider for wound treatments for the facility. During the observation, Resident #34 stated she does have pain relating to the pressure ulcer. Resident #34 stated she had the wound prior to coming to the facility but was unable to give dates and details of the wound. Interview on 11/13/24 at 9:00 AM with the ADON revealed APNP #601 continues to monitor Resident #34's wound and stated it was a stage three pressure ulcer present upon admission on [DATE]. However, ADON confirmed the first assessment for staging of Resident #34's pressure ulcer to the coccyx wasn't done until 07/01/24. The ADON verified there was no orders for treatments in Resident #34's records from 06/19/24 to 07/01/24. The ADON verified there were no documented treatments being provided to Resident #34 for the wound until 07/01/24. Interview on 11/13/24 at 9:24 A.M. with the Director of Nursing (DON) and the ADON verified the MDS dated [DATE] documented Resident #34 as having no unhealed pressure ulcers or wounds. Interview on 11/13/24 at 1:10 P.M. with NP #601, via telephone, revealed Resident #34's pressure ulcer on coccyx was present upon admission and presented as a stage three pressure ulcer, however NP #601 verified she had not physically assessed Resident #34's pressure ulcer until 07/01/24, indicating she was unaware what the wound looked like or staged prior to 07/01/24. NP #601 stated the first comprehensive assessment of the pressure ulcer at the current facility was conducted on 07/01/24. NP #601 verified the wound was documented as an unstageable due to the obscured wound bed and stated the wound was debrided and staged at a level three. Interview on 11/18/24 at 11:00 A.M. with ADON verified the wound documentation dated 07/01/24 documented Resident #34's pressure ulcer to the gluteal cleft as a new wound. Review of the facility's policy titled, 'Pressure Injury Surveillance', dated 10/2022 revealed nursing staff will monitor and assess any new or current wounds and report findings and changes. Per the policy all wounds will be tracked with a focused review and corrective action will be taken immediately. 2. Review of Resident #56's medical record revealed an admission date of 09/19/24. Diagnoses included kidney disease, type II diabetes, atrial fibrillation, mild protein malnutrition, and anxiety disorder. Review of Resident #56's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #56 was moderately cognitively impaired. Resident #56 was on hospice at the time of the review. Resident #56 was dependent on staff for toilet use, bathing, dressing, and personal hygiene. Resident #56 displayed no behaviors during the review period. Review of Resident #56's care plan revised 10/08/24 revealed supports and interventions for receiving hospice services, increased nutrition risk, risk for depression, impaired cognitive function, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 6 of 20 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 11/18/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few risk for pain, self-care deficit, and potential for pressure ulcer development. Interventions for potential for pressure ulcer development included medications as ordered, administer treatment as ordered and monitor of effectiveness, and monitor and report to the physician any changes in skin status as needed. Review of Resident #56 admission skin assessment dated [DATE] indicated Resident #56 had redness in his anal region, but no lesion or open areas were documented. Review of Resident #56's 09/19/24 progress notes revealed a clinical assessment was completed and indicated Resident #56 had redness located in his anal region. Above Resident #56's rectal area it was documented he had a one centimeter slit with slight depth. No orders or treatments were noted related to the one inch slit. Review of Resident #56's hospital information dated 10/01/24 revealed Resident #56 was transferred to the hospital for shortness of breath on 09/25/24. Resident #56 was admitted [DATE] for fluid overload while having been following along with his fluid restriction and diuresis. Resident #56 was noted to have a posterior coccyx wound on 09/25/24 which was non-blanchable and documented as an active stage one pressure wound. At the time of discharge, Resident #56's wound was noted to be a pressure ulcer stage two. Wound was cleansed with soap and water on 09/29/24 and the treatment at the time of discharge on [DATE] was to leave open to air with triad hydro/zinc oxide paste. There was no order found for treatment of Resident #56's stage two pressure wound when Resident #56 returned to the facility on [DATE]. Review of Resident #56's 10/01/24 skin check indicated Resident #56 had an open lesion, present at admission, measuring one cm in length, .2 cm width, and .1 centimeter depth. The notation indicated the wound was deteriorating. Additional care was turning and repositioning. No dressing or treatment was indicated as being in place. Resident #56's 10/08/24 skin check indicated Resident #56 had redness in his anal region and also had an open lesion, present at admission, measuring one centimeter (cm) in length, .2 cm width, and .1 centimeter depth. The notation indicated the wound was deteriorating. Additional care was turning and repositioning. No dressing or treatment was indicated as being in place. Resident #56's skin check dated 10/16/24 revealed Resident #56 continued to have an open lesion, present at admission, measuring one centimeter (cm) in length, .2 cm width, and .1 centimeter depth. The notation indicated the wound was deteriorating. Additional care was turning and repositioning. No dressing or treatment was indicated as being in place. Resident #56's skin check dated 10/23/24 revealed Resident #56 continued to have an open lesion, present at admission, measuring one centimeter (cm) in length, .2 cm width, and .1 centimeter depth. The notation indicated the wound was improving. Additional care was turning and repositioning. No dressing or treatment was indicated as being in place. Resident #56's skin check dated 11/05/24 revealed Resident #56 continued to have an open lesion noted to be on his coccyx area, present at admission measuring one centimeter (cm) in length, .5 cm width, and .2 centimeter depth. Soap and water was used as a cleansing solution. Additional care was moisture barrier, pressure reducing device for the bed, and turning and repositioning program. Resident #56's skin check dated 11/12/24 revealed Resident #56 continued to have an open lesion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 7 of 20 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 11/18/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few noted to be on his coccyx area, present at admission measuring one cm in length, .5 cm width, and .2 centimeter depth. Cleansing solution was soap and water. Additional care was moisture barrier, pressure reducing device for the bed, and turning and repositioning program. Resident #56's skin check dated 11/13/24 revealed Resident #56 continued to have an open lesion noted to be on his coccyx area, present at admission measuring .4 cm in length, .1 cm width, and .1 centimeter depth. Cleansing solution was soap and water. Additional care was moisture barrier, pressure reducing device for the bed, and turning and repositioning program. Review of Resident #56's physician orders revealed an order dated 09/20/24 and discontinued 09/28/24 for barrier to rectal area until resolved every shift for redness. Further review of Resident #56's physician orders and Treatment Administration Record (TAR) for September 2024, October 2024, and the first part of November 2024 found there were no ordered treatments found for Resident #56's coccyx lesion documented as present on admission. Review of Resident #56's Hospice information revealed Resident #56 began on hospice services on 10/02/24. No documentation regarding Resident #56's coccyx wound was found. Further review of Resident #56's hospice documentation revealed Resident #56 was approved for hospice services for a certification period of 10/02/24 to 12/30/24. Resident #56's terminal diagnosis was noted to be ischemic cardiomyopathy. Resident #56 was noted to be bed bound and required a Hoyer lift for transfer. Hospice provided hospice nursing services, hospice aide services, and hospice social worker services. A recertification visit was schedule for 12/10/24. No wound treatment orders were found. Review of fax communication from Resident #56's Hospice Team Coordinator dated 11/13/24 reported the hospice provider was unable to find any skin notes or wound care orders for Resident #56. A low air loss mattress was ordered. Observation of Resident #56 with the Assistant Director of Nursing (ADON) on 11/13/24 at 9:00 A.M. revealed the wound was an open area on the coccyx measuring 0.2 cm by 0.2 cm by 0.1 cm. Interview with the ADON on 11/13/24 at 9:08 A.M. verified the wound was not followed by the facility once the resident became a hospice patient. This resident had not been seen by nurse practitioner or herself since receiving these services due to being on hospice. Observation on 11/14/24 at 3:25 P.M. of Resident #56's coccyx wound with the Director of Nursing (DON) and ADON found Resident #56's coccyx wound measured .2 cm depth and .2 cm round. There was no drainage and no odor found. The wound bed was pink and painful when the depth was measured. The peri-wound around the circular wound was pink blanchable. Interview on 11/14/24 at 3:31 P.M. with the DON verified there was no physician order in place for Resident #56's coccyx wound. The DON stated she was just on the phone with hospice and they would be getting an order in place. The DON stated they had been using a barrier cream that the Certified Nursing Assistants (CNAs) applied since admission on for Resident #56. The ADON reported Resident #56's lesion was not followed by wound care due Resident #56 being on hospice. The skin check assessments were completed by the floor nurses and not a wound nurse. Interview on 11/18/24 at approximately 10:15 A.M. with the ADON revealed the barrier cream was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 8 of 20 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 11/18/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented as being added for Resident #56's coccyx wound as an intervention on Resident #56's 11/05/24 skin check. There was no prior documentation of the barrier cream being used for Resident #56's coccyx. The ADON provided the 09/20/24 and discontinued 09/28/24 order for Resident #56's barrier to his rectal area every shift until resolved for redness. Review of Resident #56's hospice physician order dated 11/14/24 revealed a new order was written for Thera Calazinc 3% to 20% topical cream apply to coccyx daily and as needed for skin impairment. Review of Resident #56's Hospice Nurse visit note dated 11/15/24 revealed Resident #56 had a coccyx wound with an unknown date of onset. The wound was described as pin point, not red, and blanchable. Measuring .1 cm length, .1 cm width, and .1 cm depth. The shape was round and the edges were distinct. It was noted to keep buttocks clean and dry. Apply zinc cream to area for breakdown prevention. The goal was for wound to not worsen. Review of the facility's policy titled, Pressure Injury Surveillance, dated 10/2022 revealed nursing staff would monitor and assess any new or current wounds and report findings and changes. Per the policy all wounds would be tracked with a focused review and corrective action would be taken immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 9 of 20 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 11/18/2024 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to put interventions in place in a timely manner to prevent weight loss. This affected one (Resident #55) of three reviewed for weight loss. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record of Resident #55 revealed an admission date of 09/07/24. Diagnoses included calculus of bile duct, encounter for surgical aftercare following surgery on the digestive system, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 had mild cognitive deficit. The assessment indicated no dental concerns and no swallowing or chewing difficulties. Review of the care plan dated 09/13/24 revealed a focus of increased nutrition/hydration risk related to diagnoses of calculus of bile duct in gallbladder, hypertension, history of pulmonary embolism, seborrheic dermatitis, long-term use of anticoagulants, iron deficiency anemia, and overactive bladder. A focus of at risk for impaired nutrient absorption due to polypharmacy, and obesity. Interventions included offer alternative foods when less than 50 percent (%) is eaten policy (cheese cubes, cottage cheese, peanut butter sandwich, soup and crackers, ice cream, toast, fruit, or pudding), monitor oral and fluid intake, monitor of signs and symptoms of dehydration, and monitor labs as ordered. A goal listed was to avoid having any significant, rapid, undesired weight changes. Review of the weights documented revealed an admission weight dated 09/26/24 of 185 pounds (lbs). The weight documented on 10/01/24 was 176.4 lbs, an 8.6 lbs (4.6 %) weight loss in 8 days. The next weight documented on 11/08/24 was 156.8 lbs, a 19.6 lbs (11.11 %) loss in 37 days. Review of a Mini Nutritional Assessment dated 09/09/24, documented by Dietetic Technician (DT) #422, revealed a score of 10, indicating the resident was at risk for malnutrition. The form had a care planning section, but nothing was marked. Review of a Nutrition Assessment completed on 09/16/24 by DT #244, revealed Resident #55 had a goal to meet nutritional needs through diet as evidenced by no significant weight loss. DT #55 recommended to continue with current diet, monitor weight, appetite, and labs. Review of the progress notes revealed no documentation for physician notification of the 8.6 lbs weight loss in a week. The 19.6 lbs loss in the 37 days was addressed by DT #422 on 11/12/24, four days after the weight had been obtained. Review of a progress note dated 11/12/24 written by DT #422 revealed Resident #55's meal intakes have declined. DT #422 recommended four ounces of Magic cup (nutritional supplement) be given to Resident #55 twice daily and continue to monitor current diet. The note includes to add Resident #55 to the NAR (Nutrition at Risk program). Review of the physician orders revealed an order dated 11/13/24 for Magic cup, four ounces, twice daily for nutritional supplement. Observation on 11/13/24 at 2:10 P.M. revealed the staff weighing Resident #55. The scale was at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 10 of 20 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 11/18/2024 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few zero and Resident #55, in a wheelchair, was rolled onto the scale and the obtained weight was 198.6 lbs. Resident #55 was taken back to her room and placed in bed, per her request, and the wheelchair was weighed at 42.2 lbs, for a resident weight of 156.4 lbs. Interview on 11/14/24 at 1:09 A.M. with DT #422 revealed Resident #55 eats less than 50% of meals at most mealtimes. DT #422 stated a recommendation was given to add magic cup twice daily to increase nutritional requirements. DT #422 stated the Certified Nurse Assistants (CNAs) do not document if alternates were offered/accepted. DT #422 admitted to not having noticed the 4.6 lbs weight loss from 09/27/24 to 10/01/24, and no physician notification had been made. Review of a document dated 11/08/24 revealed Physician #600 was notified by facsimile of the 19.6 lbs weight loss. Physician #600 was in the facility on 11/18/24 at 9:55 A.M. and was interviewed. The interview revealed he had received the fax but had not responded to it, choosing to do so in person. Physician #600 stated Resident #55 was a very difficulty resident choosing to refuse everything. Interview on 11/18/24 at 9:55 A.M. with Licensed Practical Nurse (LPN) #498 revealed the staff are very good at offering alternatives to residents but there is nowhere, to her knowledge, this is documented. LPN #498 stated she does chart more than other nurses but may not always document the alternatives offered and/or accepted. Interview on 11/18/24 at 12:42 P.M. with Assistant Director of Nursing (ADON) revealed there is no documentation of offering or accepting any alternatives if residents refuse or eat less than 50% of meals. Review of the policy titled, Weight/Height Policy, dated 02/27/06, revealed if a resident's weight is more than a four-pound difference for the previous weight, a re-weight will occur and indicated in the record with an asterisk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 11 of 20 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 11/18/2024 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of the facility policy, the facility failed to ensure proper oversight of a resident receiving nutrition through enteral tube feed which led the resident experiencing a significant weight loss of seven-point five percent (7.5%) in six months. This affected one (#02) of two residents reviewed for tube feeding nutrition. The census was 57. Findings included: Review of medical record for Resident #02 revealed an admission date of 02/26/24. Diagnoses including cerebral palsy, dysphasia, aphasia, gastrostomy, feeding difficulties, abnormal posture, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was severely cognitively impaired. The resident was dependent with eating. Further review revealed a weight loss of five percent or more in the last month, or a weight loss of 10 percent or more in the last six months. The resident utilized a feeding tube. Review of the physician's orders revealed an order dated 10/08/24 for weekly weight to be completed every dayshift on Monday. An order dated 09/10/24 for enteral feed every shift, Nutrien 2.0 infuse at 35 milliliters (ml) per hour for 23 hours with water flush of 30 ml each hour with a per dual flow feeding pump. Review of the care plan dated 07/05/24 revealed the resident was at nutrition and hydration risk with a goal for the resident to avoid having significant, rapid, undesired weight changes, will meet nutrition needs through enteral feeding via g-tube, and the resident will remain free of side effects or complications from enteral feeding. Interventions included to follow on Nutrition at Risk (NAR) Program, monitor for signs and symptoms of dehydration, as evidenced by poor skin turgor, cracked lips, thirst, fever, abnormal labs, concentrated urine, obtain weekly weights as resident allows, provide tube feeding, flushes, and medication flushes as ordered, provide tube feed of Nutrien 2.0 infuse at 35 ml per hour for 23 hours with water infusing at 30 ml per hour plus 150 ml flush every eight hours, through dual flow pump, 30 ml Prosource daily due to weight loss, this provides 1610 kilocalories, 82 grams of Prosource and 1697 ml fluid plus flush with medication pass, and check for tube placement and gastric contents and or residuals per facility protocol and orders. Review of Resident #02's documented weight history revealed the following: • On 05/13/24 the weight was 101.8 pounds (lbs). • On 05/20/24 the weight was 103.4 lbs. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 12 of 20 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 11/18/2024 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)

F 0693 On 05/27/24 the weight was 103.4 lbs. Level of Harm - Minimal harm or potential for actual harm • On 06/03/24 the weight was 103.6 lbs. Residents Affected - Few • On 06/10/24 the weight was 103.8 lbs. • On 06/17/24 the weight was 104.8 lbs. • On 06/24/24 the weight was 107.2 lbs. • On 07/02/24 the weight was 102.8 lbs. • On 07/08/24 the weight was 101.2 lbs. • On 07/15/24 the weight was 102.1 lbs. • On 07/22/24 the weight was 100.8 lbs. • On 07/29/24 the weight was 101.2 lbs. • On 08/04/24 the weight was 100.4 lbs. • On 08/12/24 the weight was 97.6 lbs. • On 08/19/24 the weight was 100 lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 13 of 20 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 11/18/2024 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)

F 0693 • Level of Harm - Minimal harm or potential for actual harm On 08/26/24 the weight was 98.6 lbs. • Residents Affected - Few On 09/02/24 the weight was 97.8 lbs. • On 09/09/24 the weight was 98.5 lbs. • On 09/25/24 the weight was 98.2 lbs. • On 09/30/24 the weight was 98.6 lbs. • On 10/01/24 the weight was 98.6 lbs. • On 10/14/24 the weight was 101.1 lbs. • On 10/21/24 the weight was 100.4 lbs. • On 10/28/24 the weight was 100 lbs. • On 11/10/24 the weight was 97.4 lbs. • On 11/14/24 the weight was 94.4 lbs. Further review of Residents #02 documented weight history from 09/02/24 to 11/13/24 revealed the mechanical lift was used on 09/02/24 a weight of 97.8lbs.; on 09/09/24 the weight was 98.5 lbs, on 10/28/24 the weight was 100.0 lbs., and all other weights were taken with a wheelchair. Review of the dietary progress notes on 09/06/24 through 11/01/24 revealed Resident #02 flagged for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 14 of 20 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 11/18/2024 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few significant weight loss of seven-point five percent (7.5 %) in a six-month review with recommendations to increase the tube feed from 30 ml per hour to 35 ml per hour. The goal was to meet nutritional needs through tube feed as evidenced by no significant weight loss through the next review. Continue to monitor weight and laboratories. Continue to follow on NAR. This was the first documentation which indicated weight loss This was the first documentation in progress notes which indicated a weight loss was identified and failed to acknowledge a seven-pound weight loss for the month of July 2024. Further review of the medical record revealed no documentation of how much tube feeding Resident #02 was receiving. Observation of Resident #02 on 11/13/24 at 1:15 P.M. with Certified Nurse Assistant (CNA) #476 revealed the resident was placed in her wheelchair and the weight was 187.2 lbs. The resident was placed back into bed, CNA #476 took the weight of the chair which was 93.8. The resident's weight was 93.4 lbs. The blue tag on the wheelchair was 86.6 lbs. CNA #476 verified they use the blue tag on the wheelchair to calculate her weight. CAN #476 stated the staff also used the hoyer weight, but no-one seems to know where it went. Interview with Licensed Practical Nurse (LPN) #498 on 11/13/24 at 2:00 P.M. revealed Resident #02 had a new feeding tube pump which staff are unable to hear. There are times when the resident is checked on, and the machine will have turned off for an unknown time. There was a period when there was trouble with keeping the peg tube running properly and the resident was sent to the hospital for replacements which was in June. There is no place to document the residual and or the input or output of the tube feed. An interview with LPN #464 (night shift nurse) on 11/14/24 at 5:45 A.M. revealed the tube feed for Resident #02 is changed every morning at 4:30 A.M. The amount which was left over to be discarded was about 3 inches which she indicated by her fingers and did not know the exact amount. There is no place to document the residuals, amount taken in daily, or discarded tube feed. The pump reads about 750 ml was received in the last 23 hours and most days the pump reads approximately 700 ml for most of the days and up to 750 ml per day. When asked if the nurse notified anyone of the residents not receiving the correct amount, the nurse stated, I really do not know what amount the resident does get because I did not do the math. The nurse admitted there had been weight loss for Resident #02 and there was a period where there were many problems with the feeding tube and the resident had to be sent to the hospital for repair in June. The resident's new pump will stop due to the little blue card kept coming out which would stop the pump and staff were not able to hear the pump alarm. The resident needed to be checked more often to see if the pump was still providing nutrition to the resident. The nurse verified the dietitian is the one who usually changes the orders for all tube feed residents and the nurse did not notify of the amounts of tube feed which was left over daily. There was no place to document the amount of tube feed left over or what amount was infused to the resident. Observation on 11/14/24 at 6:15 A.M. revealed CNA #470 and CNA #493 placed Resident #02 in bed and transferred her to the hoyer lift sling and lifted her up to get a weight. The weight was verified by LPN #498 was 39.1 kilograms which converts to 86.2 lbs. CNA #470 and CNA #493 verified they use the hoyer lift and or wheelchair to weigh the resident. Interview with the Director of Nursing (DON) on 11/14/24 at 10:00 A.M. verified Resident #02 had some inconsistent weights over the last few months which prompted changes made to weight monitoring to daily with specific instructions. The DON was just notified on 11/14/24 by the nurses of the tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 15 of 20 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 11/18/2024 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feed pump not working properly. The pump would shut off and the nurses were unable to hear the alarm which would leave the tube feed off for a period of unknown time. The DON verified there was no documentation of how much tube feed the resident was receiving or that the nurses were documenting the residual. Interview with Diet Technician #498 on 11/14/24 at 1:15 P.M. verified there was no notification made to inform Resident #02 was not receiving all her tube feed as physician ordered. There was no notification about the issues with the pump which was causing the resident's tube feeding to be off for unknown periods of time. Diet Technician #498 verified the resident was reviewed each week in the NAR meeting and the members were not knowledgeable about the pump issues which caused the resident to not receive the full amount of tube feed ordered. Review of the facility's policy titled, Enteral Nutrition, dated 11/18 revealed adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete. Complete orders include volume and rate of administration with supplement orders including confirmation of tube placement and gastric residual volume. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 16 of 20 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 11/18/2024 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 ensure residents had appropriate diagnosis to the support the use of an antipsychotic medication. This affected one resident (#261) of six residents reviewed for psychotropic medication use. The facility census was 57. Findings include: Review of Resident #261's medical record revealed an admission date of 11/04/24. Diagnoses included anxiety disorder, hearing loss, diverticulitis, and dysphagia. Review of Resident #261's Minimum Data Set (MDS) assessment dated [DATE] revealed an admission MDS was in progress. Review of Resident #261's care plan revised 11/06/24 revealed supports and interventions for forgetfulness, nutrition risk, history of wandering and exit seeking, self-care deficit, risk for pain, risk for falls, and use of antipsychotic medication related to anxiety. Review of Resident #261's physician orders revealed an order dated 11/06/24 for quetiapine fumarate (antipsychotic) 25 milligrams (mg) give one tablet two times a day for anxiety and sleeplessness. Review of the Medscape's indication of use for quetiapine included schizophrenia, bipolar disorder, and major depressive disorder. Anxiety disorder was not a diagnosis indicated for use of the antipsychotic medication. Review of Resident #261's progress notes revealed on 11/06/24 Resident #261 was seen by the physician and increased Resident #261's Quetiapine 25 mg to twice a day and started Namenda titration. Interview on 11/13/24 at 11:34 A.M. with Pharmacist #602 verified anxiety by itself was not a qualifying diagnosis for the use of a antipsychotic. Interview on 11/13/24 at 11:37 A.M. with the Director of Nursing (DON) verified Resident #261 was diagnosed with anxiety and was receiving Quetiapine, an antipsychotic medication. Interview on 11/13/24 at 11:39 A.M. with Physician #600 revealed Resident #261's anxiety diagnosis would be updated to included anxiety with psychosis as a justification for use of the antipsychotic. Review of the facility policy titled, Use of Psychotropic Medications, revised September 2022 revealed residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed, and documented in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 17 of 20 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 11/18/2024 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)

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, medical record review, and policy review, the facility failed to ensure insulin was administered as ordered. This resulted in a significant medication error. This affected one (Resident #15) of four observed for medication administration. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record of Resident #15 revealed an admission date of 11/22/22. Diagnoses included diabetes mellitus. Review of the physician order dated 07/26/23 revealed Novolog insulin Aspart was to be administered as per sliding scale. If the blood glucose level was 201-300 inject two units subcutaneous. A second order dated 08/01/23 revealed to inject 15 units Novolog insulin Aspart subcutaneous with meals. Observation on 11/13/24 at 7:25 A.M. revealed Registered Nurse (RN) #457 obtained a blood glucose level from Resident #15. The reading was 273 milligrams per deciliter and RN #457 checked the order and discovered the amount of Novolog insulin to be administered would have been two units. RN #457 obtained the Novolog insulin and a syringe and drew up two units of Novolog and administered the medication to Resident #15. Interview on 11/13/24 at 8:40 A.M. with RN #457 revealed she had only administered two units Novolog insulin to Resident #15 and ordered 15 units as scheduled, verifying the error. Review of the policy titled, Obtaining a Fingerstick Glucose Level, revised 10/11, revealed to ensure the glucose meter is cleaned and disinfected between resident use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 18 of 20 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 11/18/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, the facility failed to ensure medications were not expired. This had the possibility to affect all 57 residents residing in the facility. The facility census was 57. Findings include: Observation at 10:50 A.M. of the large supply room with Licensed Practical Nurse (LPN) #498 revealed the following over-the-counter medications for residents: one bottle of fiber powder dated best by 3/24, one bottle of Calcium D 5 micrograms dated best by 6/24, one bottle of oyster calcium 500 milligrams (mg) dated best by 4/24 and three bottles dated best by 8/24, one bottle of melatonin 3 mg dated best by 10/24, and one bottle of acetaminophen liquid 500 mg in 15 milliliters dated best by 3/24. LPN #498 immediately verified the findings and removed the bottles from the room to dispose of them. The facility failed to produce a policy for medication storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 19 of 20 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 11/18/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and policy review, the facility failed to ensure a glucometer device was disinfected between resident use. This had the potential to affect three (Residents #03, #12, and #15) identified by the facility as having blood glucose monitoring. The facility census was 57. Residents Affected - Few Findings include: Observation on 11/13/24 at 7:25 A.M. revealed Registered Nurse (RN) #457 obtained a blood glucose reading on Resident #15 using a shared glucometer and used an alcohol prep pad to cleanse the device. Immediately following the cleansing, RN #457 verified the use of the alcohol prep to cleanse the device and stated, I suppose that is the wrong disinfection solution. RN #457 then looked through the medication cart and found no disinfection cloths. Interview on 11/13/24 at 7:27 A.M. with Director of Nursing revealed the solution to disinfect the glucometer should have been a Sani-Wipe disinfecting cloth, not alcohol. Review of the policy titled, Obtaining a Fingerstick Glucose Level, revised 10/11, revealed to ensure the glucose meter is cleaned and disinfected between resident use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366144 If continuation sheet Page 20 of 20