Health inspection·August 22, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident financial records, interview with facility staff and review of facility policy revealed the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) for one (#41) of three residents reviewed for appropriate SNF/ABN notifications. The census was 64. Residents Affected - Few Findings include: Review of the medical record of Resident #41 admitted to the facility on [DATE] with diagnoses including cerebral infarction, cellulitis, major depressive disorder, anemia, arthritis, morbid obesity, sleep apnea, anxiety, and hyperlipidemia. Her most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 has a Brief Interview of Mental Status (BIMS) score of 08, indicating she has a moderate cognitive impairment. Review of Resident #41's Notice of Medicare Non-Coverage (NOMNC) revealed her last covered day of skilled services was 06/27/19. Resident #41's financial Power-of-Attorney (POA) was notified on 06/24/19 via phone. Resident #41 continued her stay in the facility and a SNF/ABN was necessary. Review of the SNF/ABN revealed Resident #41 signed the SNF/ABN on 08/21/19. During an interview on 08/22/19 at 9:43 A.M., Director of Residential Services confirmed Resident #41's SNF/ABN was not signed until 08/21/19. Director of Residential Services stated she had been on vacation when Resident #41 was issued her NOMNC and the staff member covering for her did not issue the SNF/ABN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 2 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to provide documentation residents and responsible parties were provided a notice of transfer upon transfer from the facility. This affected two residents (#7, #41) of three residents reviewed for hospitalization. The facility identified three residents who had transferred from the facility in the last 30 days. The facility census was 65. Findings include: 1. Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses include altered mental status, acute kidney failure, osteoarthritis, falls, neuralgia and neuritis, pain right shoulder, gastro-esophageal reflux disease, disorientation, obstructive uropathy, sepsis, difficulty walking, bursitis of hip,muscle weakness, infection and inflammation due to indwelling urethral catheter, muscle weakness, anxiety, transient ischemic attack ( mini-stroke), urinary tract infection, urine retention. sciatica and gout. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive deficits and verbal and behavioral symptoms. Extensive assistance was required for all activities of daily living except for supervision with eating. Review of a progress note dated 05/04/19 at 8:40 A.M., revealed Resident #7 was found unresponsive and was sent to the emergency room. Review of a Transfer notice dated 05/04/19 revealed Resident #7 was sent to the hospital due to an emergency. The Ombudsman's name was listed and it revealed the notification was sent to the Ombudsman. Review of Lima convalescent Home Transfer/discharge Notice signed 09/29/17 revealed the Administrator was to notify the resident and resident's sponsor in writing by certified mail, return receipt requested in advance of any proposed transfer or discharge from the home. Further review of the medical record for Resident #7 revealed no documentation was available regarding providing a notice of transfer to the resident's responsible party. Interview with Medical Records Clerk #200 on 08/22/19 at 9:20 A.M., revealed she filled out a transfer notice and sent it to the Ombudsman when Resident #7 was sent to the hospital. She stated she had been instructed to copy the notice and send it to the family. She stated she did not keep any documentation of any notifications she had sent. She stated she emailed the Ombudsman with each transfer and did not have a monthly notification. 2. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes acute embolism of the left femoral vein, mild cognitive impairment, heart failure, hyperlipidemia, lymphedema, and severe protein calorie malnutrition. Review of the progress notes dated 08/03/19 at 7:06 P.M. revealed Resident #41 was sent the hospital for evaluation and treatment related to lymphedema of the left lower extremity. Continued review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 3 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 0623 Level of Harm - Minimal harm or potential for actual harm of the progress notes revealed the resident was admitted to the hospital. The resident returned to the facility on [DATE]. Review of the medical record for Resident #41 revealed no evidence the resident or the resident representative was given notice of the reason of transfer to the hospital in writing. Residents Affected - Few Interview on 08/22/19 at 8:59 A.M. with the director of nursing verified the facility did not give Resident #41 or the resident's representative notice of the reason for the transfer to the hospital in writing on 08/03/19. Review of an undated discharge notice form revealed the facility must notify the resident and representative in writing of the reason for transfer or discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 4 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to provide residents and responsible parties with a bed hold notice upon transfer from the facility. This affected two residents (#7, #41 ) of three residents reviewed for hospitalization. The facility identified three residents who had transferred from the facility in the last 30 days. The facility census was 65. Findings include: 1. Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses include altered mental status, acute kidney failure, osteoarthritis, falls, neuralgia and neuritis, pain right shoulder, gastro-esophageal reflux disease, disorientation, obstructive uropathy, sepsis, difficulty walking, bursitis of hip,muscle weakness, infection and inflammation due to indwelling urethral catheter, muscle weakness, anxiety, transient ischemic attack ( mini-stroke), urinary tract infection, urine retention. sciatica and gout. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive deficits and verbal and behavioral symptoms. Extensive assistance was required for all activities of daily living except for supervision with eating. Review of a progress note dated 05/04/19 at 8:40 A.M. revealed Resident #7 was found unresponsive and was sent to the emergency room. Review of a Bed-holding Agreement signed 09/27/17 revealed the resident responsible party was informed of abed hold policy on 09/27/17. Further review of the medical record for Resident #7 revealed no documentation was available regarding providing a bed hold policy being provided to the resident's responsible party. Interview with Director of admission #250 on 08/22/19 at 10:30 A M. revealed residents/responsible parties were informed of the bed hold policy on admission and signed the form at that time. He verified the bed hold agreement/policy was not reviewed each time the resident was transferred from the facility. He further verified the responsible party for Resident #7 was not provided a bed hold policy upon the resident's transfer to an acute care hospital on [DATE]. 2. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes acute embolism of the left femoral vein, mild cognitive impairment, heart failure, hyperlipidemia, lymphedema, and severe protein calorie malnutrition. Review of the progress notes dated 08/03/19 at 7:06 P.M. revealed Resident #41 was sent the hospital for evaluation and treatment related to lymphedema of the left lower extremity. Continued review of the progress notes revealed the resident was admitted to the hospital. The resident returned to the facility on [DATE]. Review of the medical record for Resident #41 revealed no evidence the resident or the resident representative was notified of the facilities policy for bed hold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 5 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 0625 Level of Harm - Minimal harm or potential for actual harm Interview on 08/22/19 at 8:59 A.M. with the director of nursing verified the facility did not give Resident #41 or the resident's representative the facilities policy for bed hold. Review of a policy titled, Bed Hold revised 12/18, revealed information about the facilities bed hold policy will be provided in writing at the time of a transfer for hospitalization or therapeutic leave. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 6 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected two (#4 and #59) of 18 residents reviewed for accuracy of the assessment. The census was 65. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with behavioral disturbance, lack of expected normal physiological development, mood affective disorder, retention of urine, hyperlipidemia, anxiety, major depressive disorder, and convulsions. Review of the medication administration record dated 07/19, revealed Resident #4 was administered Xarelto (anticoagulant medication) 20 milligrams on 07/24/19, 07/25/19, 07/26/19, and 07/27/19. Review of a quarterly MDS assessment dated [DATE], revealed no assessment of the anticoagulant medications administered to Resident #4 during the seven day reference period. Interview on 08/21/19 at 2:26 P.M. with registered nurse (RN) #560 revealed Resident #4 was administered anticoagulant medication on 07/24/19, 07/25/19, 07/26/19, and 07/27/19. RN #560 verified the Resident #4's quarterly MDS assessment dated [DATE], was not accurate. 2. Review of the medical record of Resident #59 revealed an admission date of 05/05/19 and a discharge date of 05/31/19. Diagnoses included pneumonia, benign neoplasm of pancreas and acute respiratory failure with hypoxia. Review of the discharge summary note dated 06/27/19 revealed Resident #59 was admitted on [DATE] from acute care for follow up care related to septic pneumonia with the goal to return home. Elder received therapy services, medication management, respiratory support, lab monitoring for low hemoglobin and hematocrit, and activity of daily living support. Home evaluation completed, discharged home on [DATE] with home health services and follow up appointments with doctors. Review of the Minimum Data Set (MDS) dated [DATE] revealed in the identification information section (A) revealed the resident was coded as discharge return not anticipated, with discharge status as acute hospital. Interview with 08/22/19 at 8:10 A.M. with the Assisted Director of Nursing #600 verified for Resident #59 the information in the MDS dated [DATE] was an error due to her being discharged to home and it will need to correct it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 7 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 review of medical records, interview with facility staff, and review of facility policy, the facility failed to provide a final summary of residents status and reconcile medications for one (Resident #57) of one residents reviewed for discharge. The census was 65. Findings include: Review of Resident #57's medical record revealed an admit date on 05/23/19, with diagnoses including: hernia with obstruction, osteoarthritis, kidney disease, sleep apnea, obesity, congestive heart failure, mixed incontinence, dementia, and hypertensive heart and chronic kidney disease. Resident #57 discharged to an adjoining Residential Care Facility on 06/08/19 with his wife. Resident #57's most recent Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview of Mental Status of 07, indicating a severe cognitive impairment. The MDS also revealed he required extensive assistance with his activities of daily living. Review of a form titled Resident Discharge summary, dated [DATE], revealed the functional status, level of assistance needed and condition upon discharge were left blank. Where the form stated Discharging to: was left blank, as well as home health services and outpatient services. Future appointments were listed. Labs to be drawn after discharge were also included. The form also revealed a medication reconciliation was not performed. Resident #57's wife signed the discharge summary. During an interview on 08/22/19 at 8:58 A.M. with Licensed Practical Nurse (LPN) #500 revealed she was the nurse who discharged Resident #57. LPN #500 confirmed the following areas on Resident #57's discharge summary were left blank: functional status, level of assistance, condition upon discharge, discharge location, home health and/or out patient services and verified there was no evidence medication reconciliation was completed. Review of a facility policy titled, Transfer and Discharge, last revised 12/03/18 revealed the resident or representative would received verbally and in writing, a copy of the post-discharge plan which would include the current medication list, current treatments, diet recommendations, and any post-discharge medical and non-medical services. Review of a facility policy titled, Advanced Beneficiary Notice, updated 12/05/18, revealed the resident or resident representative would be notified of the last day to be covered by Medicare at least two days in advance of the last covered day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 8 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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. Based on medical record review and staff interview, the facility failed to ensure as needed (prn) medication used longer than 14 days were reevaluated by a physician. This affected one (#47) of five residents reviewed for unnecessary medications The facility census was 65. Findings include: Review of medical record for Resident #47 revealed an admission date of 05/02/19 with diagnosis that include depression, mental disorders, diabetes, hallucinations, and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #47 dated 07/12/19 revealed impaired cognition. The resident required extensive assist for bed mobility, transfers, dressing, toileting and personal hygiene. Further investigation of MDS revealed anxiety medication was administered during the look back period. Review of physician orders for the month of May 2019 for Resident #47 revealed an order dated 05/23/19 for Ativan (name brand anxiety medication) 0.5 milligrams (mg) take one tablet by mouth every eight hours as needed for anxiety for the next two months. Review of the physician progress notes for Resident #47 dated 5/23/19 and 06/30/19 were silent for documentation regarding the rationale for the two month order for antianxiety medication. Interview with Director of Nursing on 8/21/19 at 11:58 A.M., verified that the physician did not re-evaluate the prn Ativan every fourteen days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 9 of 10 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 366297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lima Convalescent Home 1650 Allentown Road Lima, OH 45805 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 medical record review, staff interview and review of the manufacturer's instructions, the facility failed to ensure insulin was given per physician's order by ensuring the insulin Kwik Pen was primed prior to administrating the dosage of medication. This affected one (#51) of two residents observed for insulin administration. The census was 65. Residents Affected - Few Findings include: Record review of Resident #51 revealed an admission date of 07/12/19. Diagnosis include Diabetes Mellitus. Review of the physician's orders for Resident #51 revealed an order for Humalog mix 75/25 Kwik Pen Suspension (75/25) 100 units per milliliter (ml), to inject 40 units subcutaneously two times a day with meals. Observation on 08/21/19 at 8:05 A.M. of medication administration on Resident #51 with Licensed Practical Nurse (LPN) #500 revealed she cleaned the Kwik Pen Humalog 75/25 with alcohol, placed a new needle on it. She rolled the pen until it was evenly distributed then dialed up 40 units. She did not prime the pen, but gave the 40 units in the right upper arm. Interview with LPN# 500 on 08/21/19 at 8:36 A.M., verified she did not prime the needle prior to dialing up the 40 units also she was told to only prime the quick pens when they were new. She then realized she did not give the full dose of 40 units and actually injected her with two units of air. Interview with the Director of Nursing on 08/21/19 at 9:58 A.M. verified she had spoken to the doctor on the phone regarding LPN#500 whom did not prime the Kwik Pen during administration of insulin to Resident #51. The doctor did not want any actions to be taken but agreed this should have been primed prior to administration which resulted in inaccurate dose being given. Review of the manufacture's instructions for use Humalog Kwik Pen revised date of 12/2018 revealed to prime before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 10 of 10