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. Page 1 of 5 366144 366144 06/03/2025 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0580 This deficiency represents non-compliance investigated under Complaint Number OH00165153. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366144 Page 2 of 5 366144 06/03/2025 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of facility policy, the facility failed to ensure residents were provided with assistance for activities of daily living (ADL's). This affected 10 (#10, #11, #12, #13, #14, #15, #16, #20, #21 and #22) residents residing on the secured dementia unit. The facility census was 58. Residents Affected - Some Findings include: Review of medical record for Resident #10 revealed admission date of 04/21/25 with diagnoses including pneumonia, atrial fib and heart failure. The resident remained in the facility. Review of Resident #10's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required supervision for eating, max assist for toileting and moderate assistance for bed mobility and transfers. Review of medical record for Resident #11 revealed admission date of 09/24/19 with diagnoses including Parkinson's, dementia, stroke, and dysphagia. The resident remained at the facility. Review of Resident #11's annual MDS dated [DATE] revealed she had moderately impaired cognition and she/he required limited assistance for eating, extensive one person assistance for bed mobility, toileting and transfers. Review of medical record for Resident #12 revealed admission date of 11/25/24 with diagnoses including dementia with severe psychotic disturbances, dementia and hypertension. The resident remained in the facility. Review of Resident #12's quarterly MDS dated [DATE] revealed BIMS score of 04 indicating severely impaired cognition. She required supervision for eating, bed mobility, transfers and extensive assistance for toileting. Review of medical record for Resident #13 revealed admission date of 07/06/17 with diagnoses including dementia, anxiety, psychotic disorder with delusions. The resident remained at the facility. Review of Resident #13's quarterly MDS dated [DATE] revealed moderately impaired cognition. She required extensive two-person assistance with toileting, one-person assistance for bed mobility, dependent for transfers and limited assistance for eating. Review of medical record for Resident #14 revealed admission date of 02/14/25 with diagnoses including paraplegia and dementia. The resident remained at the facility. Review of Resident #14's quarterly MDS dated [DATE] revealed with a BIMS score of 11 indicating impaired cognition. She required set up assistance for eating, maximum assistance for bed mobility and was dependent for toileting hygiene and transfers. Review of medical record for Resident #15 revealed admission date of 08/08/24. The resident was admitted with diagnoses including Parkinson's. The resident remained in the facility. 366144 Page 3 of 5 366144 06/03/2025 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of Resident #15's quarterly MDS dated [DATE] revealed with a BIMS score of 14 indicating intact cognition. She was independent with her ADL's. Review of medical record for Resident #16 revealed admission date of 11/14/22 with diagnoses including Alzheimer's Disease and dementia. The resident remained at the facility. Residents Affected - Some Review of Resident #16's quarterly MDS dated [DATE] revealed severely impaired cognition. She required supervision with eating, maximum assistance with bed mobility and was dependent for transfers and toileting hygiene. Review of medical record for Resident #20 revealed an admission date of 11/30/18 with diagnoses including Alzheimer's Disease, dementia and anxiety. The resident remained at the facility. Review of Resident #20's quarterly MDS dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 01 indicating severely impaired cognition. She required extensive one-person assistance for her ADL's. Review of medical record for Resident #21 revealed admission date of 11/30/18 admitted with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, dysphagia and heart failure. The resident remained at the facility. Review of Resident #21's annual MDS dated [DATE] revealed a BIMS score of 03 indicating severely impaired cognition. The resident was she/he required extensive two-person assistance for bed mobility, transfers, toileting and limited assistance for eating. Review of medical record for Resident #22 revealed admission date of 03/28/23 admitted with diagnoses including unspecified dementia with severe psychotic disturbance, behavioral disturbance, anxiety and depression. The resident remained at the facility. Review of Resident #22's quarterly MDS dated [DATE] revealed with a BIMS score of 03 indicating severely impaired cognition. She required extensive one-person assistance for eating. And supervision for bed mobility, toileting and transfers. Review of the facility supplied statement from Certified Nursing Assistant (CNA) #74 documented she had worked on 05/16/25 and when she returned on 05/17/25 the residents on the secured dementia were dressed in the same clothes and required incontinence care. Three staff attended to the resident's ADL needs. Interview on 06/03/25 at 9:35 with CNA #67 revealed she had worked on 05/18/25. CNA #67 stated an agency aid (CNA #75) had worked a double shift prior to her arrival and had left without giving her report. CNA #67 shared several residents were asleep in their recliners and the same clothes as when she left her the day prior. CNA #67 stated a nurse was notified and management had investigated the incident. Interview on 06/03/25 at 2:48 P.M. with the Director of Nursing (DON) revealed she was on call on 05/18/25 and was informed by nursing that CNA #74 had reported when she arrived for her shift the residents were in the same clothes as she had left them in the previous day and required incontinence care. The DON shared an investigation was initiated and a Self-Reported Incident (SRI) was created. The DON stated CNA #75 had worked the front part of the 100 hall on 05/16/25 without incident. On 366144 Page 4 of 5 366144 06/03/2025 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 05/17/25, CNA #75 worked a double shift on the back part of the hall and did not provide the resident's assistance with their ADL's as evidenced by the residents had not been changed out of the clothes from the previous day and required incontinence care. The DON stated skin sweeps were completed without concern and two cognitively intact resident's were interviewed and no concerns/outcomes were identified. The DON confirmed this affected 10 (#10, #11, #12, #13, #14, #15, #16, #20, #21 and #22) residents residing on the secured dementia unit. The DON placed CNA #75 and two agency nurses who worked with him on the Do Not Return (DNR) list for the facility. The DON also reported CNA #75 to the Ohio Department of Health. The DON stated audits were initiated to ensure residents on the back of the 100 hall were well-groomed, had received/eaten meal and were clean and dry. These audits were performed three times a week and she provided documentation they had been completed without incident at the time of the survey. The DON shared the facility CNA's had been educated to perform walking rounds at the start/end of their shifts to ensure ADL's were completed. The DON did acknowledge agency staff were still being scheduled on all shifts and had not provided this information. The DON verified there was no documentation staff had received education to prevent another incident. Interview on 06/03/25 at 3:59 P.M. with CNA #69 revealed walking rounds were not completed at the start of her shift. Interview on 06/03/25 at 4:06 P.M. with Registered Nurse (RN) #71 revealed she encouraged the CNA's to do walking rounds to ensure residents were clean and dry. RN #71 shared at least one to two times weekly she was informed by her CNA's that resident's required incontinence care at the start of the shift. When she asked them if walking rounds were completed, they informed her they had not. Review of the facility policy, Activities of Daily Living revised 03/2018 documented appropriate care and services would be provided for residents who were unable to carry out ADL's independently and in accordance with the plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00166006. 366144 Page 5 of 5