Health inspection·June 30, 2022

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on review of personal fund accounts, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents had access to personal funds. This affected one (#39) out of 26 residents with personal fund accounts. The facility census is 58. Residents Affected - Few Findings include: Review of the personal fund accounts revealed Resident #39 had an account managed by the facility. Review of the most recent quarterly statement revealed as of 06/27/22 Resident #39's remaining balance was $29.95. Observation on 06/27/22 at 12:27 P.M. revealed Resident #39 requested $10 of personal funds from Activities Assistant #429. Activities Assistant #429 asked numerous questions to Resident #39 of why she needed the money and what she planned to purchase. Resident #39 avoided the question for a couple of instances and made a short joking remark. Activities Assistant #429 stated the Business Office Manager was out that day and Resident #38 could not obtain her funds until tomorrow. Medical Records Clerk #432 offered to loan Resident #39 $10 until the next day. Interview on 06/27/22 at 12:30 P.M. with Resident #39 verified she was told she could not access $10 from her account because the Business Office Manager was out of the building. Interview on 06/27/22 at 1:31 P.M. with Activities Assistant #429 verified telling Resident #39 the Business Office Manager was out of the office and she could not access her money. Activities Assistant #429 reported Resident #39 had an appointment with transportation and often attempts to get the driver to stop so she can purchase candy. Activities Assistant #429 reported Resident #39 has diabetes and should not eat candy. Interview on 06/30/22 at 10:53 A.M. with Business Office Manager #434 verified she was not working on 06/27/22. Business Office Manager #434 stated there is a process in place to ensure residents have access personal funds at all times, even when she is out of the office. Review of the facility policy titled Resident Funds, revised June 2020, revealed the facility will provide a means for the resident to access his or her funds. Page 1 of 16 366162 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0583 Keep residents' personal and medical records private and confidential. 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, observation, staff interview, and review of facility policy, the facility failed to provide privacy when clipping a resident's toe nails for one (#313) resident randomly observed. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record revealed Resident #313 was admitted on [DATE]. Diagnosis included Alzheimer's disease, major depressive disorder, and dementia. Observation on 06/28/22 at 10:55 A.M. revealed Licensed Practical Nurse (LPN) #455 clipping Resident #313's toe nails in the resident common area. Residents also present in the common area included Resident #8, #22, #34, #35, #40, #56, and #59. Interview on 06/28/22 at 11:11 A.M. with Licensed Practical Nurse (LPN) #455 verified clipping Resident #313's toe nails in the common area. Review of facility policy titled Quality of Life, created on 11/13/17, revealed the resident shall be cared for in a manner that is respectful and dignified in recognition of their individuality. 366162 Page 2 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, resident interview, staff interview and review of the facility policy, the facility failed report to the State Survey Agency an allegation when a resident intentionally poured water onto a confused resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58. Findings include: Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively intact. Review of Resident #39's progress notes revealed the record was silent of any resident to resident interactions. Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago Resident #54 came into her room and Resident #39 had told her to leave repeatedly. Resident #39 stated Resident #54 would not leave and continued to state she wanted a shower. Resident #39 stated she gave her what she wanted by sprinkling Resident #54 with water then dumping the rest of the cup of water on Resident #54. Resident #39 reported facility staff were upset with her at the time for dumping water on another resident and she was instructed to next time use her call light. Review of Resident #54's medical record revealed an admission dated of 02/21/17. Diagnoses includes anoxic brain damage, type two diabetes, irritability and anger, violent behavior, cognitive communication deficit, and unsteadiness on feet. Review of the MDS assessment, dated 05/21/22, revealed the resident was severely cognitively impaired. Review of Resident #54's progress note, dated 05/27/22 at 4:59 P.M., revealed the resident was intermittently wandering the unit and at times attempting to go into other resident rooms. One on one redirection and frequent toileting attempts with minimal success were attempted to prevent wandering into other rooms. Staff monitoring resident to attempt to prevent incident. Interview on 06/28/22 at 3:19 P.M. with State Tested Nursing Assistant (STNA) #422 verified hearing about an incident between Resident #39 and Resident #54 about two to three weeks ago. Interview on 06/28/22 at 3:26 P.M. with Resident #54 revealed the resident had no recollection of the incident. Review of Self-Reported Incidents (SRI) for 2022 revealed no SRI had been initiated regarding a resident to resident altercation between Resident #39 and Resident #54. 366162 Page 3 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0609 Level of Harm - Minimal harm or potential for actual harm Interview on 06/29/22 at approximately 12:00 P.M. with the Administrator and Registered Nurse (RN) Regional Nurse #456 verified they were aware of an interaction between Resident #39 and #54 on an unknown date when Resident #39 splashed water on Resident #54. RN Regional Nurse #456 reported the Director of Nursing (DON) called the Administrator who had called RN Regional Nurse #456. They determined a self-reported incident was not required because there was no intent to harm. Residents Affected - Few Interview on 06/29/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #435 verified on 05/26/22 Resident #39 dumped approximately 120 cubic centimeter (cc) of water on Resident #54 after she would not leave her room and repeatedly stated she wanted a shower. LPN #435 reported water was observed on Resident #54 shirt near the waistband. LPN #435 reported neither resident was upset about the incident and Resident #39 laughed. LPN #435 stated she did believe it was a resident to resident incident and called the on-call manager to report the concern. Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, reviewed 02/2021, revealed the definition of abuse includes the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. It includes mental abuse. The definition of willful meant the individual must have acted deliberately, not that the individual intended to inflict injury or harm. The an allegation of abuse should be reported to the Ohio Department of Health (ODH) immediately, but not later than twenty four hours after the allegation is made. 366162 Page 4 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, resident interview, staff interview and review of the facility policy, the facility failed investigate an allegation when a resident intentionally poured water onto a confused resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58. Residents Affected - Few Findings include: Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively intact. Review of Resident #39's progress notes revealed the record was silent of any resident to resident interactions. Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago Resident #54 came into her room and Resident #39 had told her to leave repeatedly. Resident #39 stated Resident #54 would not leave and continued to state she wanted a shower. Resident #39 stated she gave her what she wanted by sprinkling Resident #54 with water then dumping the rest of the cup of water on Resident #54. Resident #39 reported facility staff were upset with her at the time for dumping water on another resident and she was instructed to next time use her call light. Review of Resident #54's medical record revealed an admission dated of 02/21/17. Diagnoses includes anoxic brain damage, type two diabetes, irritability and anger, violent behavior, cognitive communication deficit, and unsteadiness on feet. Review of the MDS assessment, dated 05/21/22, revealed the resident was severely cognitively impaired. Review of Resident #54's progress note, dated 05/27/22 at 4:59 P.M., revealed the resident was intermittently wandering the unit and at times attempting to go into other resident rooms. One on one redirection and frequent toileting attempts with minimal success were attempted to prevent wandering into other rooms. Staff monitoring resident to attempt to prevent incident. Interview on 06/28/22 at 3:19 P.M. with State Tested Nursing Assistant (STNA) #422 verified hearing about an incident between Resident #39 and Resident #54 about two to three weeks ago. Interview on 06/28/22 at 3:26 P.M. with Resident #54 revealed the resident had no recollection of the incident. Review of Self-Reported Incidents (SRI) for 2022 revealed no SRI had been initiated regarding a resident to resident altercation between Resident #39 and Resident #54. Interview on 06/29/22 at approximately 12:00 P.M. with the Administrator and Registered Nurse (RN) 366162 Page 5 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0610 Level of Harm - Minimal harm or potential for actual harm Regional Nurse #456 verified they were aware of an interaction between Resident #39 and #54 on an unknown date when Resident #39 splashed water on Resident #54. RN Regional Nurse #456 reported the Director of Nursing (DON) called the Administrator who had called RN Regional Nurse #456. They determined a reported the residents were laughing about it and there was no intent to harm therefore an investigation was not completed. Residents Affected - Few Interview on 06/29/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #435 verified on 05/26/22 Resident #39 dumped approximately 120 cubic centimeter (cc) of water on Resident #54 after she would not leave her room and repeatedly stated she wanted a shower. LPN #435 reported water was observed on Resident #54 shirt near the waistband. LPN #435 reported neither resident was upset about the incident and Resident #39 laughed. LPN #435 stated she did believe it was a resident to resident incident and called the on-call manager to report the concern. Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, reviewed 02/2021, revealed the definition of abuse includes the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. It includes mental abuse. The definition of willful meant the individual must have acted deliberately, not that the individual intended to inflict injury or harm. Once the Administrator is notified an investigation of the allegation violation will be conducted. . 366162 Page 6 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record review and staff interview, the facility failed to transmit Minimum Data Set, (MDS) assessments for three (#266, #267, and #2) out of 24 residents reviewed for MDS assessments. The current census was 58. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #266 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hip replacement, cancer, hypertension, and pressure ulcers. The resident was discharged from the facility in 03/2022. Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #266. 2. Record review for Resident #267 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #267 include heart disease, renal failure, and thyroid disease. The resident was discharged from the facility in 03/2022. Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #267. 2. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include anemia, hypertension and diabetes. The resident was discharged from the facility in 03/2022. Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #2. Interview on 06/28/22 at 2:00 P.M. with the Regional Nurse #456 verified the facility had not employed a MDS nurse since 03/2022. The Regional Nurse #456 verified the MDS assessments had not been completed and transmitted. 366162 Page 7 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview the facility failed to complete a baseline care plan with oxygen included as a focus for three residents, (#264, #34, and #213) out of five residents reviewed for baseline care plans. The current census is 58. Findings include: 1. Record review of Resident #264 revealed the resident had been admitted to the facility on [DATE]. Diagnoses for Resident #264 include dementia with behaviors, diabetes, falls, neuralgia, and cognitive deficit. Review of Resident #264's Minimum Data Set (MDS) assessment, dated 06/18/22, revealed the resident had impaired cognition and received supplemental oxygen. Review of the physician orders dated 06/14/22 revealed the resident was to receive oxygen to maintain oxygen level above 90 percent. Review of Resident #264's baseline care plans, dated 06/14/22, revealed no care plan for for oxygen. Per the care plans dated 06/26/22 the resident had a goal added to the 'basic needs' focus with the intervention of oxygen as ordered. Interview on 06/28/22 at 3:14 P.M. with the Registered Nurse (RN) Regional Nurse #456 verified the use of oxygen was not addressed in the 06/14/22 baseline care plan. Review of policy titled Comprehensive Care Plan/Baseline, revised October 2018, revealed a baseline care plan will be initiated within 48 hours of resident being admitted . The baseline care plan will be the temporary working care plan until the comprehensive care plan is completed. 2. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication deficit, osteoarthritis, hypertension, and Alzheimer's disease. Review of the MDS assessment, dated 04/26/22, revealed the resident was cognitively impaired. Review of Resident #34's record review revealed a baseline care plan had not been completed. The comprehensive care plan was initially completed on 02/25/22. Interview on 06/30/22 at approximately 12:30 P.M. with RN Regional Nurse #456 verified a baseline care plan for Resident #34 could not be located. 3. Review of the medical record for Resident #213 revealed an admission date of 06/22/22. Diagnoses included chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia. Review of the current physician orders revealed an order dated 06/22/22 for Resident #213 to have a #6 Shiley uncuffed tracheostomy (trach)in place to maintain patent airway, and to check every 366162 Page 8 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0655 Level of Harm - Minimal harm or potential for actual harm shift. Further review revealed an order dated 06/22/22 for Resident #213 to receive 30% cool aerosol via trach collar at bedside with oxygen 2 liters per minute via pressure line adapter. Review of the baseline care plan dated 06/22/22 revealed no care plan for Resident #213's tracheostomy care or supplemental oxygen. Residents Affected - Few Interview on 06/28/22 at 5:06 P.M. with the Director of Nursing (DON) confirmed Resident #213's baseline care plan did not include care areas for the tracheostomy or supplemental oxygen. 366162 Page 9 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete comprehensive care plans for one (#34) out of 24 residents reviewed for care plans. The current census was 58. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication deficit, osteoarthritis, hypertension, and Alzheimer's disease. Review of Resident #34's comprehensive care plan revealed it wasn't completed until 02/25/22. Interview on 06/30/22 at approximately 12:30 P.M. with Registered Nurse Regional Nurse #456 verified Resident #34 was admitted on [DATE] and a comprehensive care plan was not initiated until 02/25/22. 366162 Page 10 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

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, resident interview, family interview, review of the facility policy, and staff interview, the facility failed to conduct care conferences with residents and their families. This affected two (#6 and #39) out of three residents reviewed for care conferences. The facility failed to revise a care plan following the assessment of one (#34) out of 24 residents reviewed for care plans. The current census was 58. Findings include: 1. Review of the medical record of Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic bronchitis, dementia with behaviors, heart disease, weakness, history of fractures, and depression. Review of Resident #6's Minimum Data Set (MDS) assessment, dated 06/03/22, revealed the resident had impaired cognition and behavior, and was a two person assistance with Activities of Daily Living, (ADL). Further review of Resident #6's medical records revealed there was no documentation of care conferences being conducted from 06/2021 through 06/2022. Interview on 06/27/22 at 11:36 A.M. with Resident #6 and her daughter revealed the facility has not planned, conducted, or discussed the care of the resident with the resident and her daughter on a quarterly basis. Per Resident #6's daughter she attended care conferences last year but none were scheduled or offered in 2022. The resident's daughter stated she has requested care conferences with the staff but have the staff have not honored her request. Interview on 06/29/22 at 4:00 P.M. with Licensed Social Worker (LSW) #408 verified there was no documentation in the Resident #6's record for care conferences having occurred. Per the social worker there had been no care conferences conducted with the team, the resident, and her family since 06/2021. 2. Review of Resident #39's medical record revealed an admission date of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, weakness, sleep apnea, lymphedema, and hypertension. Review of the MDS assessment, dated 05/09/22, revealed the resident was cognitively intact. Review of the care plan conferences revealed Resident #39 had not had a care plan conference since 07/02/20. Interview on 06/29/22 at 4:24 P.M. with LSW #408 revealed on 06/29/22 she documented a care plan conference with Resident #39 that was held on 04/28/22. LSW #408 verified she has not planned or held formal care conferences in the past year with any residents. LSW #408 verified if it was not documented they were not complete. 366162 Page 11 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included protein-calorie malnutrition, acute respiratory failure with hypoxia, cognitive communication deficit, hyperlipidemia,, hypertension, restlessness and agitation, dementia, type two diabetes mellitus, and Alzheimer's disease. Review of the MDS assessment, dated 04/26/22, revealed the resident was cognitively impaired. The assessment revealed there were no current pressure ulcers. Review of the comprehensive care plan, initiated on 02/25/22, revealed a current care plan for pressure ulcers, including a stage three area on the coccyx. Review of the medical record revealed, dated 03/17/22, revealed the pressure ulcer to the coccyx was resolved. The care plan was not updated to show the resolved area. Interview on 06/28/22, at an unknown time, with Registered Nurse (RN) Regional Nurse #456 verified Resident #34's care plan had not been updated with the resolved pressure ulcer. 366162 Page 12 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

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. Based on resident interview, staff interview and record review, the facility failed to obtain orders for the flushing of a gastrostomy tube (g-tube) upon admission to the facility, failed to provide flushes as ordered by the physician, and failed to have a policy regarding g-tube care and treatment . This affected one (#213) of one resident reviewed for a g-tube. The facility census was 58. Findings include: Review of the medical record for Resident #213 revealed an admission date of 06/22/22 with diagnoses of chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia. Review of physician orders upon admission revealed an order for an oral diet. There were no orders upon admission for g-tube flushes. Review of a physician order dated 06/24/22 revealed Resident #213's g-tube should be flushed with 60 milliliters (mL) of water every eight hours to maintain patency. Review of the treatment administration record (TAR) for Resident #213 revealed g-tube flushes were not given on 06/24/22 at 10:00 P.M., on 06/25/22 at 6:00 A.M., 2:00 P.M., and 10:00 P.M., on 06/26/22 at 6:00 A.M., on 06/27/22 at 2:00 P.M., on 06/28/22 at 2:00 P.M. and on 06/29/22 at 2:00 P.M. Interview on 06/27/22 at 11:30 A.M. with Resident #213 revealed he had a g-tube but did not use it for nourishment or hydration. The facility was unable to provide a policy regarding g-tube care or treatment. Interview on 06/30/22 at 10:32 A.M., Assistant Director of Nursing (ADON) #446 confirmed the order for Resident #213's g-tube flushes started two days after admission. Further interview confirmed flushes were not documented on eight occasions and she could not provide verification the flushes were given on those occasions. 366162 Page 13 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and staff interview, the facility failed to provide oxygen per physician order for one (#40) out of two residents reviewed for oxygen therapy. The current census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 04/09/20 with medical diagnoses of dementia, paranoid personality disorder, and insomnia. Review of the quarterly Minimum Data Set assessment, dated 05/09/22, revealed Resident #40 had severely impaired cognition, required extensive assistance of one person for bed mobility and transfers, and limited assistance of one person for toilet use and hygiene. Review of a physician order dated 10/21/21 revealed Resident #40 received oxygen therapy at 2 liters per minute (L/min) per nasal cannula every shift as needed for dyspnea and respiratory distress. Review of the medication administration record (MAR) for Resident #40 dated 06/27/22 through 06/29/22 revealed no documentation of the resident having any dyspnea or respiratory distress and no documentation oxygen was administered. Observation on 06/27/22 at 2:49 P.M. revealed Resident #40 sitting in the common area receiving oxygen via nasal cannula at 3 L/min. Interview on 06/27/22 at 3:04 P.M. with Licensed Practical Nurse (LPN) #457 confirmed Resident #40's oxygen was running at 3 L/min. Interview on 06/27/22 at 5:40 P.M. with LPN #435 revealed a State Tested Nurse Aide (STNA) had applied Resident #40's oxygen and increased it above the physician's ordered rate. Further interview revealed STNAs should not adjust oxygen rates. Observation on 06/28/22 at 9:55 A.M. revealed Resident #40 sitting in the common area receiving oxygen via nasal cannula at 2 L/min. Observation on 06/29/22 at approximately 10:00 A.M. revealed Resident #40 sitting in the common area receiving oxygen via nasal cannula at 2 L/min. Interview on 06/29/22 at 4:36 P.M. with LPN #410 confirmed Resident #40 had oxygen on earlier in the day on 06/29/22. Interview on 06/30/22 at 10:23 A.M. with the Assistant Director of Nursing #446 confirmed Resident #40's MAR revealed no documentation oxygen was administered 06/27/22 through 06/29/22. 366162 Page 14 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on staff interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides (STNA) received annual in-services. This affected two (STNA #401 and STNA #414) our of 18 STNAs employeed and had the potential to affect all 58 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel files for STNA #401 revealed a hire date of 06/24/13. There was no evidence of the completion of 12 hours of in-services every 12 months. Review of the personnel files for STNA #414 revealed a hire date of 04/21/04. There was no evidence of the completion of 12 hours of in-services every 12 months. Interview on 06/30/22 at 1:30 P.M. with the Director of Human Resources confirmed the STNAs had not completed 12 hours of in-services over the last 12 months. 366162 Page 15 of 16 366162 06/30/2022 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the facility failed to have a physician attend quarterly QAA committee meetings. This had the potential to affect all 58 residents in the facility. Residents Affected - Many Findings include: Review of the sign-in sheets for the quarterly QAA meetings dated 07/27/21, 12/28/21, 03/29/22, and 06/29/22 revealed the physician was not present during the meetings on 07/27/21 and 12/28/21. Interview on 06/30/22 at 3:52 P.M. with the Administrator confirmed the physician did not attend QAA meetings during the third and fourth quarters of 2021. 366162 Page 16 of 16