Health inspection·August 15, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance with toilet use. Resident #54 had an indwelling catheter at the time of the review. Resident #54 displayed no behaviors during the review period. Review of Resident #54's care plan revised 07/15/22 revealed supports and interventions for risk for infection related to suprapubic catheter and risk for complications related to use of suprapubic catheter due to retention of urine and obstructive uropathy. Interview on 08/08/22 11:18 A.M. with STNA #174 revealed Resident #54 had a catheter bag which had no cover and he was currently out of the facility at an appointment. STNA #174 reported they didn't have catheter dignity bags for Resident #54 and she didn't know where to get them. Observation on 08/08/22 at 11:32 A.M. of Resident #54 found him propelling himself in his motorized wheelchair back into the home. Coinciding interview with Resident #54 verified he was returning home from a medical appointment. Resident #54's catheter bag was uncovered and lying on the footrest of his motorized wheelchair. Resident #54 stated he didn't have a cover for his catheter bag that he knew of. STNA #174 verified Resident #54's catheter bag was not covered and he had been out in public outside the facility. Review of the facility policy titled, Dignity, revised February 2021 revealed staff were to promote, maintain, and protect resident privacy. Urinary drainage bags must be covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 2 of 11 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 08/15/2022 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident and staff interviews and policy review, the facility failed to accommodate resident needs by ensuring the resident's call lights were within reach. This affected four (#24, #30, #34, and #122) out five residents sampled for accessibility of call lights. Facility census was 71. Residents Affected - Some Findings include: Observation on 08/08/22 at 4:55 P.M. revealed Resident #122 was sitting up in bed with her dinner tray in front of her. Resident #122 stated she did not like what they served her for dinner. When asked if she had told staff she stated she couldn't tell staff due to no being able to reach her call light. Resident #122's call light was on the bottom bar of the enabler side rail with the button pointing to the floor out of the reach of the resident. On 08/08/22 at 5:00 P.M. an interview with State Tested Nursing Assistant (STNA) #224 verified Resident #122 could not reach her call light. On 08/09/22 at 2:10 P.M. observations revealed Resident #30 was lying in bed. Resident #30 stated she had a wet depends on that she couldn't get rid of. When asked if her depends needed changed she stated yes. The soft touch call light was hanging off the bed on the bottom bar of her right enabler side rail out of the reach of the resident. Interview with STNA #234 on 08/09/22 at 2:15 P.M. verified Resident #30 was not able to reach her call light. On 08/10/22 at 7:15 A.M. observation of Resident #24, #30, #34, and #122 revealed call lights were draped around the bottom bar on the enabler side rails hanging down towards the floor out of the reach of the residents. On 08/12/22 at 7:25 A.M. an interview with Licensed Practical Nurse (LPN) #240 verified Resident #24, #30, #34 and #122 call lights were out of reach. LPN #240 stated the call lights needed to be clipped to the resident's clothing as this is their direct line to access staff. Review of an undated policy titled Call Light revealed staff should keep nurses' call system within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 3 of 11 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 08/15/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interviews and policy review, the facility Residents Affected - Few failed to ensure hand splints were applied as recommended by therapy and/or ordered by the physician. This affected two (#29 and #30) two residents reviewed for limited range of motion. The facility census was 71. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including spastic hemiplegia affecting his left non dominant side, major depressive disorder, osteoarthritis, vascular dementia, seizure disorders, anemia, and diabetes type II. Review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six revealing he has a severe cognitive deficits. Resident #29 displayed physical behaviors toward others on one to three days of the assessment. Resident #29 is totally dependent for all activities of daily living except eating which he requires supervision of one person. Resident #29 is non ambulatory. Resident #29 has functional limitation in range of motion to his upper extremities on one side. Review of the plan of care updated 06/07/22 stated Resident #29 is at risk for alteration in comfort and pain related to osteoarthritis of his left hand and history of a stroke with left hemiplegia. Resident #29 has had botox in his left hand in the past. Interventions included a left hand splint at bedtime as tolerated per order and monitor skin for breakdown with application and removal of the splint. Review of a physician order dated 06/01/22 stated to apply a left hand splint. The splint is to be taken off during morning care, applied at lunch, taken off at dinner and applied at bedtime. The order stated to contact occupational therapy with any concerns. Review of the Occupational Therapy Discharge Summary, dated 06/14/22, revealed the OT recommendation was for Resident #29 to have a left hand splint (hand roll) placed eight hours a day per wearing schedule. Observation on 08/09/22 at 2:10 P.M. revealed Resident #29 was in reclining chair at the dining room table with another resident drinking strawberry lemonade. Resident #29's left hand was in a fist with his left arm flaccid lying on his left leg. Resident #29 stated they do not work with his left hand or put a splint on it. Resident #29 stated the only one who does anything with his hand is his son. Observation of Resident #29's room on 08/09/22 at 2:14 P.M. revealed a hand roll splint over the faucet in the sink. Interview with State Tested Nursing Assistant (STNA) #212 on 08/09/22 at 2:15 P.M. verified Resident #29 had a splint for his left hand contracture. STNA #212 stated it had become soiled and she had to wash the splint and let it air dry. STNA #212 verified there was nothing currently in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 4 of 11 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 08/15/2022 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 0688 #29's left hand. Level of Harm - Minimal harm or potential for actual harm Interview with Licensed Practical Nurse (LPN) #195 on 08/09/22 at 2:20 P.M. verified Resident #29 was to have a soft hand splint on his left hand placed on after lunch until dinner. The splint is to be off at dinner and on at bedtime then off for morning care. LPN #195 verified Resident #29 did not have anything in his left hand at the time. LPN #195 verified there was no extra splints to use while the original hand splint was drying. F Residents Affected - Few Interview with Certified Occupational Therapy Assistant (COTA) #600 on 08/10/22 at 2:00 P.M. verified Resident #29 was to wear a splint in his left hand to protect the skin on the palm of his hand and prevent the contracture of his left hand from contracting further. COTA #600 verified the splint was a hand roll and should be worn eight hours a day per splint schedule. COTA #600 stated the splint schedule is in the STNA's tasks for instructions and documentation. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with left hemiparesis, obsessive compulsive disorder, diabetes hypertension, and peripheral vascular disease. Review of Resident #30's quarterly MDS assessment dated [DATE] revealed the resident scored an eight on the BIMS indicating moderate cognition deficits. Resident #30 displayed physical behaviors one to three days a week during the assessment. Resident #30 requires extensive assistance of two staff for bed mobility, transfers and personal hygiene. Resident #30 is non ambulatory and has limited range of motion on one side of upper extremities. Review of plan of care dated 06/10/22 revealed Resident #30 is at risk for knowledge deficits for use of hand splint for contracture . The interventions included treatment as ordered and keep hand splint clean and dry, and monitor skin under hand splint. Review of a physician order dated 07/23/22 revealed Resident #30 is to have a left hand splint. There were no directions for use. Review of Occupational Therapy Discharge Summary, dated 05/10/22, revealed the recommendations indicated Resident #30 was to wear a left hand splint (hand roll) eight hours a day per wearing schedule. Observation on 08/10/22 at 2:00 P.M. revealed Resident #30 was in bed with her left hand lying on the mattress with her hand in a fist. There was no splint on Resident #30's left hand. Interview with STNA #234 on 08/10/22 at 2:10 P.M. verified Resident #30 was to have a splint to her left hand after lunch off at dinner and back on at bedtime. STNA #234 verified Resident #30 did not have a splint on her left hand at the present time and stated she was unable to find the splint. Interview with COTA 600 on 08/10/22 at 2:00 P.M. verified Resident #30 was to wear a splint in her left hand to protect the skin on the palm of her hand and prevent the contracture of her left hand from contracting further. COTA #600 verified Resident #30's splint was a hand roll and should be worn eight hours a day per splint schedule. COTA #600 stated Resident #30's splint schedule is in the STNA's tasks for instructions and documentation. Review of undated policy titled Contracture Management indicated nursing staff is to follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 5 of 11 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 08/15/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm suggested physician interventions to manage changes in baseline limb movement and prevent further decline. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 6 of 11 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 08/15/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review the facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident did not elope from the locked unit. This affected one (#41) out of three residents reviewed for elopement. The facility census was 71. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include encephalopathy, diabetes, falls, maxillary fracture, chronic kidney disease, heart failure, tremors, dementia without behaviors. Review of Resident #41's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a one-person assist for Activities of Daily (ADL). Review of the admission wandering risk assessment dated [DATE] revealed Resident #41 was assessed as being a low risk for wandering. Review of Resident #41's progress notes revealed on 06/09/22 the resident's family had concerns for Resident #41's wandering so they requested a Wanderguard. Per the note the physician agreed. Review of the care plans dated 06/08/22 revealed a focus for wandering from facility unattended due to dementia, depression, and anxiety. Interventions include allow the resident to wander in appropriate areas but remove from area if annoying peers, check alarm system to ensure safety, encourage to walk with a buddy to activities, frequent checks, medications per order, redirect attention, one-on-one (1:1) interactions, take on walks, take to common areas if wandering. Review of Resident #41's progress notes dated 07/21/22 revealed at 12:45 P.M. the nurse was notified by the aide that Resident #41 had left the gated patio area she was in with her Assisted Living (AL) visitor. Per the note, the AL visitor was aware he did not have permission to leave the locked unit with Resident #41. Per the note the nurse called the AL unit and the staff had located the resident in the AL. The nurse notified the Licensed Social Worker (LSW) #152, the Administrator, the physician and the resident's family representative. Interview on 08/09/22 at 3:15 P.M. with Licensed Practical Nurse (LPN) #157 revealed Resident #41 does not exhibit exit seeking behaviors by herself. Per LPN #157 she has a friend from the AL she had a relationship with while she was residing on the AL unit that comes to visit her. LPN #157 showed the surveyor the gated patio area Resident #41 and her visitor were visiting when the incident on 07/21/22 occurred. Per LPN #157, the gate has a locking mechanism on the outside that can be reached and unlocked by reaching through the gate and using force to lift the lock and push the gate open. LPN #157 stated Resident #41 was not capable of opening the locked gate by herself due to her condition. LPN #157 verified the resident's AL visitor could open the gate and leave with the resident if the staff did not supervise the visitation. LPN #157 stated the AL visitor did not have permission from the facility or the family of Resident #41 to leave the locked unit with the resident. LPN #157 stated the AL visitor visited Resident #41 on a daily basis but was to be supervised by staff. LPN #157 stated she assessed Resident #41 after the incident on her shift and found the resident to have no injuries and did not appear to be any distress after the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 7 of 11 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 08/15/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/09/22 at 4:26 P.M. with Licensed Social Worker (LSW) #152 and the Administrator revealed on 07/21/22 around 12:30 P.M. Resident #41 and a visitor, a resident from AL unit were visiting and staff let the resident and her visitor out to the gated patio connected to the locked dementia unit. Per the Administrator Resident #41 had a previous relationship with the AL resident who was visiting her in the locked unit and did so on a daily basis. The Administrator stated staff went to check on Resident #41 and the AL resident around 12:45 P.M. when they noticed the resident and the visitor were no longer in the gated patio area. The Administrator stated the aide immediately notified the nurse who began the missing person procedure. The aide was instructed to go to the AL unit to search for Resident #41 as she had been a previous resident on the AL unit and may have been going back to the AL unit with her visitor. Per the Administrator the nurse notified staff on the AL unit and the staff began to search for Resident #41. The Administrator and LSW #152 stated they had been notified by the nurse of the resident leaving the patio area with her AL visitor. Per the Administrator the resident had been gone for less than 10 minutes from the patio before being found in the AL unit. The LSW stated the nurses assessed the resident and found her to have no injuries and to be in no distress. LSW #152 verified the AL visitor was not given permission from the facility or Resident #41's family to take the resident out of the SNF unit to the AL unit. The Administrator verified the staff were to supervise visitations with Resident #41 and her AL visitor. Review of the facility policy titled, 'Missing Person', dated 08/2018 revealed staff are to monitor residents at risk for wandering and elopement, precautions are to be taken to prevent the residents from eloping. This deficiency substantiates Complaint Number OH00131650. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 8 of 11 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 08/15/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of facility policy, the facility failed to ensure the physician responded to the pharmacist's recommendations for a gradual dose reduction and a end date for an as needed medication. This affected one (#2) out of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the hospital on [DATE]. Diagnoses include anxiety, hemiplegia, hypotension, mood affective disorder, dementia with behaviors, depression and falls. Review of Resident #2's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving anticoagulant, antipsychotic, anti-anxiety, and opioid medications for seven days. Review of care plans for Resident #2 dated 12/2018 revealed a focus for potential for adverse effect related to anti-psychotic, antidepressant, anti-anxiety, and medications that stabilize her mood. Interventions include medication increased due to increased behavior, administer antipsychotic medications, assure medications are swallowed, monitor effected of medications and update physician if having behaviors, monitor for side effects of medications, pharmacist/physician to review medications routinely to assure lowest effective dose. Review of Resident #2's physician prescribed medications revealed on 01/31/21, the resident was receiving Lorazepam 0.5 milligrams (mg) every two hours as needed for anxiety. On 04/09/21 the resident was to receive Risperdal 0.25 mg two times a day for behaviors and mood disorder. Review of the pharmacy reviews revealed on 01/19/21 the pharmacist recommended the physician re-evaluate the medication for need and provide a stop date for the as needed medication. No documentation of a physician response to the recommendation was noted in the resident's record. Review of the pharmacy reviews revealed on 09/17/21 the pharmacist sent a recommendation to the physician to review the Risperdal 0.25 mg twice a day for mood disorder for a possible gradual dose reduction. Further medical record review revealed there was no documented physician response was noted in the resident's record. Interview on 08/11/22 at 8:30 A.M. with the Director of Nursing (DON) verified there were no documented physician responses to the pharmacist's recommendations on 01/19/21 and 09/17/21 for the Lorazepam and the Risperdal. Review of the facility policy titled 'Antipsychotic Medication Use', dated 12/2016 revealed all antipsychotic medications are to be prescribed at the lowest dose for the shortest period of time and are subject to gradual dose reduction and re-review. The physician shall respond appropriately by changing the medications or by clearly documenting the rationale for continued use of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 9 of 11 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 08/15/2022 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. **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 ensure a resident was free from unnecessary psychotropic medication usage when the facility failed to have an adequate indication for use for an antipsychotic medication. This affected one (#32) of five residents reviewed for unnecessary medications. The facility census was 71. Findings Include: Review of Resident #32's medical record revealed an admission dated of 05/14/21 and a readmission date of 04/13/22. Diagnoses included history of heart failure, rapid heart rate, dementia with Lewy bodies, epilepsy, dysphagia, major depressive disorder, and cognitive communication deficit. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #32 was cognitively intact. Resident #32 required extensive assistance with transfer, dressing, toilet use, and personal hygiene. Resident #32 required physical help in part of the bathing activity. Resident #32 displayed no behaviors during the review period. Resident #32 had depression and no psychotic disorder at the time of the review. Review of Resident #32's care plan revised 07/27/22 revealed supports and interventions for use of antidepressant medications related to major depressive disorder and risk for potential side effects related to psychotropic medication use. It was noted Resident #32 received antipsychotic medications to stabilize her mood. Review of Resident #32's physician orders revealed an order dated 04/13/22 and discontinued 06/22/22 for Seroquel (antipsychotic medication) 25 milligrams (mg)-give 0.5 mg tablet by mouth at bedtime for cognitive communication deficit. An order dated 06/28/22 for Seroquel 25 mg-give 0.5 mg tablet by mouth at bedtime for cognitive communication deficit. Review of Resident #32's Psychiatric Reviews dated 06/09/22 and 07/06/22 revealed Resident #32 was receiving Seroquel 12.5 mg at bedtime for cognitive communication deficit. Interview on 08/11/22 at 8:12 A.M. with the Director of Nursing (DON) verified cognitive communication deficit was not an appropriate diagnosis for the use of the antipsychotic medication Seroquel. Review of the facility policy titled, Antipsychotic Medication Use, revised December 2016 revealed residents would only receive antipsychotic medications when necessary to treat a specific condition for which they were indicated and effective. Antipsychotic medication shall generally be used only for the following diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders: schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, psychosis in the absence of dementia, medical illness with psychotic symptoms and or treatment related psychosis or mania, Tourette's disorder, Huntington Disease, hiccups, or nausea and vomiting associated with cancer or chemotherapy. Antipsychotic medications will not be used if they only symptoms were one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying that is not related to depression or other psychiatric disorders, fidgeting, nervousness or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 10 of 11 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 08/15/2022 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 uncooperativeness. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366297 If continuation sheet Page 11 of 11