Health inspection·May 18, 2022

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/12/22 at 8:44 A.M. with the Director of Nursing (DON) confirmed Resident #52 had an order for palm protectors and documentation did not verify if they were utilized. The DON indicated the restorative program had not been ongoing up until recently when a restorative nurse was started. The DON could not verify how long residents were not receiving restorative programs. Interview on 05/12/22 at 12:19 P.M. with Restorative Nurse #372 confirmed she was new to the program and working on getting the program restarted. Restorative Nurse #372 verified Resident #52 did not receive restorative services as care planned for an undetermined amount of time. Resident #52 had not been wearing splints or palm guards and had not been re-evaluated by therapy. 2. Record review for Resident #65 revealed an admission date of 11/08/17. Diagnoses included hemiplegia affecting the right side, contracture of the left hand, abnormal posture and lack of coordination. Review of the active physician orders dated 09/29/18 revealed Resident #65 was to wear a left hand splint for six to eight hours daily during first shift and was to be encouraged to wear bilateral knee braces for six to eight hours a day. Review of the care plan dated 02/28/22 revealed Resident #65 had impairment. Interventions included apply left hand splint to be on six hours a day. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65's cognition was impaired. Resident #65 had impairment of one side to the upper and lower extremities and received splint or brace assistance. Observation on 05/10/22 at 11:28 A.M. revealed Resident #65 had a contracture to the left hand and bilateral lower extremities. Resident #65 was not wearing a left hand splint or knee braces. Observation and interview on 05/11/22 at 2:18 P.M. with STNA #338 revealed she worked first shift on 05/09/22, 05/10/22 and 05/11/22 and Resident #65 did not have the left hand splint or knee braces on during those times. Interview on 05/11/22 at 2:46 P.M. with Registered Nurse (RN) #301 revealed she worked full time day shift and was Resident #65's charge nurse. RN #301 confirmed Resident #65 was not wearing a left hand splint or knee braces. RN #301 said she did not know what Resident #65's braces and splint even looked like. RN #301 located the splint and braces in Resident #65's closet and stated, I have never even seen these before, I don't think he has ever had them on when I have been here. RN #301 verified Resident #65 had orders for a left hand splint and braces. Interview on 05/11/22 at 02:56 P.M. with DON confirmed Resident #65 was to have a left hand splint and knee braces on per the physician orders. 3. Record review for Resident #80 revealed an admission date of 06/29/21. Diagnoses included ataxia (loss of full control of body movement), muscle weakness, and left hip contracture of muscle. Further record review revealed revealed Resident #80 received physical therapy (PT) services from 01/20/22 through 03/29/22. Review of the PT Discharge summary dated [DATE] revealed discharge recommendations which included restorative nursing programs The programs included range of motion which staff were established and trained. Staff led supine to the bilateral lower extremities (BLE) passive range of motion (PROM) exercises in all available planes for three sets times 10. Staff led bilateral knee extensions and hip extension stretches held one minute times three each. The documentation included prognosis was good with consistent staff follow through. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366323 If continuation sheet Page 2 of 3 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 366323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayside Farm Inc 4557 Quick Rd Peninsula, OH 44264 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 Residents Affected - Some Interview on 05/12/22 at 10:54 A.M. with Restorative Nurse #372 revealed Resident #80 was discharged from therapy recently and was not receiving restorative services. Restorative Nurse #372 revealed she had recently accepted the restorative nurse position, (she was unsure of how long ago), and confirmed there had not been a program for an undetermined amount of time prior to that. Restorative Nurse #372 said there were no recommendations from therapy for Resident #80 that she was aware or she would have initiated the program. Interview on 05/12/22 at 11:07 A.M. with Certified Occupational Therapy Assistant (COTA) #355 revealed he was the therapy manager at the time Resident #80 was discharged from therapy. COTA #355 verified the recommendations for restorative therapy was given to staff and staff were educated on the restorative care to be provided to Resident #80 after discharge from therapy. COTA #355 said the recommendation would be given to the nurse at the time of discharge. The recommendation provided to the nurse was the hand off from therapy to restorative and restorative would take over. Review of the therapy recommendations revealed the training was documented from therapy to restorative. Interview on 05/12/22 at 11:12 A.M. with the DON revealed the restorative program was re-implemented two to three months ago. There was no restorative program for an undetermined amount of time prior to that. The DON revealed she did not know the process when a resident was discharged from therapy but Restorative Nurse #372 would know the process and implement the programs. Review of the facility policy titled Assistive Devices and Equipment, dated January 2020, revealed the facility maintained and supervised the use of assistive devices and equipment for residents. These devices included but were not limited to specialized equipment, hand splints, etc. Recommendations for use of devices and equipment were documented in the resident's care plan. Review of the facility policy titled Restorative Nursing Services, dated July 2017, revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing consisted of nursing interventions that may or may not be accompanied by formal rehab services. Restorative goals and objectives were individualized and resident centered and were outlined in the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366323 If continuation sheet Page 3 of 3