Health inspection·June 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to timely notify a resident's representative of change of condition in the resident. This affected one (#19) of three residents reviewed for change of condition. The facility census was 58. Findings included: Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnosis of malignant of cardia, lymph, and lung and diabetes type two. Review of Resident #19 nursing note dated 04/23/25 at 5:20 A.M. revealed Resident #19 was hard to arouse, opens eyes to name but then closes eyes. Finger blood sugar was 150. At 5:23 A.M., nine-one-one (911) for hospital transportation was called, at 5:25 A.M. notification was made to the physician, at 5:26 A.M. emergency squad arrived, at 5:27 A.M. report was called to the hospital and at 5:38 A.M. squad left facility for route to hospital. Husband was not notified due to not having husband's contact information. Review of Resident #19's of nursing note date 04/23/25 at 12:44 P.M. revealed Resident #19's husband came to facility unaware Resident #19 was transferred to hospital. Staff collected husband's contact information and shared information with the hospital. The physician spoke with husband. Interview on 06/03/25 at 9:28 A.M. with Licensed Practical Nurse (LPN) #63 revealed she was the nurse that completed the nursing portion of the admission assessment for Resident #19. LPN #63 stated Resident #19 was alert, answering questions appropriately, and understood questions. LPN #63 stated Resident #19's husband was present in the room during admission assessment. LPN #63 verbalized social worker completes the demographic information and gets family phone numbers. Nursing does not look at demographics during the admission process. LPN #63 confirmed she did not obtain Resident #19's representative information on who to contact in the event of an emergency or change of condition. LPN #63 confirmed when Resident #19 was sent to the hospital on [DATE] the family was not timely notified of the hospitalization because the facility didn't have the contact information. Interview on 06/03/25 at 10:00 A.M. with Licensed Social Worker (LSW) #65 revealed LSW #65 gets most of her contact information for resident usually from the hospital demographic page that is faxed from the hospital before the resident arrives and then from resident/family. LSW #65 confirmed the facility did not obtain Resident #19's representative information on who to contact in the event of an emergency or change of condition. (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 5 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 06/03/2025 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)