Health inspection·October 24, 2019

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 and staff interview, the facility failed to ensure residents were properly positioning with positioning devices while in wheelchairs. This affected two (Residents #239 and #354) of three residents reviewed for positioning. The facility census was 390. Residents Affected - Few Findings Include: 1. Review of Resident #239's medical record revealed an admission date of 07/08/19. Diagnoses included mood disorder, anxiety disorder, depressive disorder, dementia, history of falling, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment listed the resident as requiring extensive to total assistance for locomotion on and off the unit. Review of Resident #239's care plan dated 08/15/19 revealed the resident utilized a tilt in space wheelchair. Observation on 10/22/19 at 2:41 P.M. of Resident #239 revealed the resident sitting up in tilt in space wheelchair with no head support on the wheelchair. There was no device for the resident to lay his head on. Observation on 10/23/19 at 9:12 A.M. revealed the resident sitting in tilt in space wheelchair with no head support on the wheelchair. Interview on 10/23/19 at 10:12 A.M. with Occupational Therapist (OT) #104 verified Resident #239 did not have a head rest in place on his tilt in space wheelchair. OT #104 stated when the resident was discharged from OT services the tilt in space wheelchair did have a head rest. At the time of the interview, OT #104 observed the tilt in space wheelchair and she noted the bracket for the head rest had been removed. Observation on 10/24/19 at 9:56 A.M. revealed the resident sitting in tilt in space wheelchair with no head support on wheelchair. 2. Review of Resident #354's medical record revealed an admission date of 04/08/11. Diagnoses included schizophrenia, peripheral vascular disease, diabetes, hypertension, history of falls, dysphagia, and chronic kidney disease. Review of the MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment listed the resident as being totally dependent on staff for locomotion on the unit. Review of Resident #354's care plan dated 05/03/19 revealed the resident utilized a tilt in space wheelchair with elevating leg rests. Review of Resident #354's physician order dated 05/03/19 revealed an order for tilt in space wheelchair with elevated leg rests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 2 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 10/22/19 at 9:13 A.M. of Resident #354 revealed the resident reclined in tilt in space wheelchair with no foot rests in place and legs dangling. Observation on 10/23/19 at 10:13 A.M. of the resident revealed the resident sitting in tilt in space wheelchair with no leg rests and legs dangling. Interview at the time of the observation with OT #104 verified Resident #354 did not have leg rests in place on his tilt in space wheelchair. Observation on 10/24/19 at 10:00 A.M. of the resident revealed the resident sitting in tilt in space wheelchair with no leg rests and legs dangling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 3 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, review of hospital documentation, review of mechanical lift manufacturer instructions, review of facility mechanical lift policy, and review of facility incident investigation documentation, the facility failed to ensure residents were provided with appropriate supervision during a transfer using a mechanical lift. This resulted in actual harm when Resident #433 sustained a 5.0 centimeter (cm) laceration to the right anterior shin which required suturing. The resident was being transferred with a mechanical lift with only one staff person. This affected one (Resident #433) of three residents reviewed for use of mechanical lift for transferring. Facility census was 390. Findings include; Review of the medical record revealed Resident #433 was admitted to the facility on [DATE]. Diagnoses included myasthenia gravis, type II diabetes mellitus, dementia, major depression, chronic obstructive pulmonary disease, post traumatic stress disorder, chronic kidney disease, atrial fibrillation, anxiety disorder, chronic respiratory failure, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #433 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of activities of daily living (ADL), and required extensive physical assistance of two staff for bed mobility, transfer, and personal hygiene. The resident utilized a wheelchair for mobility. Review of a a physician order dated 04/27/17 revealed the resident required a non-weight bearing (Hoyer) lift to be used at all times for all transfers. Review of a nursing plan of care dated 07/24/19 was initiated to address fall risk. Interventions included the resident was an assist up in manual wheelchair daily. Additionally, a plan of care was developed on 07/24/19 to address the residents need for assistance with ADLs. Interventions included two staff assist with ADLs. There was no documentation on the care plans that indicated the number of staff to support the resident during a mechanical Hoyer lift for transfer. Review of an evaluation report for skin injury form, located in the medical record, revealed on 10/03/19 at 6:30 P.M. the resident was alert and oriented times two. The nurse was attempting to transfer Resident #433 with the mechanical Hoyer lift. The lift got stuck and the residents leg was stuck between the bed and the lift (Hoyer). The nurse attempted to remove the residents leg and the corner of the box on the Hoyer lift sliced the residents leg open, resulting in a laceration to the lateral right lower extremity. The lift indicated the battery was full but the lift would not go up. Review of nursing notes dated 10/03/19 at 7:16 P.M. revealed Resident #433's right anterior shin had an open area measuring 5.0 cm in length with adipose tissue exposure. Non-weight bearing Hoyer lift malfunctioned while licensed practical nurse (LPN) #400 was assisting the resident to bed. The resident sustained a large laceration with a large amount of bleeding. Pressure was placed to the laceration for over five minutes until bleeding stopped. The resident was subsequently sent to the emergency room for treatment. Review of nursing notes dated 10/03/19 at 7:25 P.M. noted the resident was being transferred to bed by LPN #400 when his leg hit on part of the Hoyer. State Tested Nurse Aide (STNA) #300 reported the Hoyer was not working properly. The maintenance staff were informed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 4 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 removed the lift from service. Level of Harm - Actual harm Review of hospital documentation dated 10/03/19 noted the resident was treated for a laceration of the leg. The resident was placed on an antibiotic Keflex 500 milligrams (mg) every six hours for seven days and had six sutures placed to close the injury. Residents Affected - Few On 10/24/19 at 8:15 A.M. interview with STNA#302 revealed residents were transferred either using one assist or two assist depending on their functional status and ability to comply with instructions while using the lift. Some residents were transferred using one staff member. On 10/24/19 at 9:10 A.M. interview with the Director of Nursing (DON) during a review of the facility full body mechanical lift instructions (policy) updated 04/04/19 noted in red print indicating all transfers involving the use of full body mechanical lift require two assist for transfer. The DON was unaware the mechanical lift policy required two staff to be utilized during a mechanical (Hoyer) lift transfer. On 10/24/19 at 11:04 A.M. interview with Resident #433, in his room, revealed when he sustained the laceration to his leg only one staff member performed the mechanical lift. Since that incident single staff members have provided transfers using the Hoyer lift from bed to chair and chair to bed. On 10/24/19 at 11:15 A.M. interview with LPN #401 and LPN #402 revealed they would use one person for transferring residents during a Hoyer lift transfer. The LPN's were unaware the facility policy indicated two staff were required. Further interview during a review of nursing and STNA care plans identified no documentation to direct staff on a specific number of staff to assist with Hoyer lift transfers. On 10/24/19 at 11:44 A.M. interview with STNA #301 during a review of STNA care plan intervention verified no directive was listed for Resident #433 referring to the number of staff to be present during a Hoyer lift transfer. On 10/24/19 at 1:43 P.M. interview with Assistant DON #101 verified she was unaware the Hoyer lift policy indicated two staff were to be utilized with mechanical lift transfers. According to the skin injury status post Hoyer lift malfunction investigation undated verified LPN #400 was transferring Resident #433 using the full body mechanical lift. LPN#400 was alone when the lift malfunctioned causing Resident #433's leg to become stuck between the bed frame and the lift. When LPN#400 attempted to remove Resident #433's leg from between the bed and lift, Resident #433's leg struck the corner of the Hoyer lift box and caused a laceration to his leg. The laceration resulted in Resident #433 being transported to the hospital emergency room to have six sutures put into place to close the wound. As a result of the incident corrective action was noted to remove the broken Hoyer lift from service. No documentation included staff utilized the appropriate number of staff when transferring residents while using the full body mechanical lift or the timely reporting of malfunctioning equipment. Review of manufacturer instructions for EZ Way Smart Lift (mechanical lift) revised 06/13/11 revealed the lift was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patients condition, two caregivers may be necessary. Review of facility policy entitled Full Body Mechanical Lift Bed To Chair Transfer Work (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 5 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 Instructions with a revised date of 04/04/19 revealed all transfers involving the use of full body mechanical lift require two assist for transfer. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 6 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation and staff interview, the facility failed to provide staff recipes for pureed diets. This directly affected 14 residents (#3, 21, 89, 114, 164, 200, 232, 250, 300, 364, 377, 381, 383 and 384) who the food was prepared for. The facility identified 19 residents who received a pureed diet. The facility census was 390. Findings include: Observation on 10/23/19 at 8:29 A.M., revealed [NAME] #165 placed eight slices of bread in a food processor with roast beef and gravy. After pureeing the mixture, [NAME] #165 divided the mixture into seven separate containers, covered the containers with plastic wrap and marked each container with a specific unit (unit A, D1 and D2, 2 North, B, C, D and 1 North) to be served to the residents on each unit who were ordered a pureed diet. Interview on 10/23/19 at 9:21 A.M., [NAME] #165 revealed she was not sure how may slices of bread she was supposed to use per serving for each pureed open face roast beef sandwich. [NAME] #165 further revealed she did not have a recipe to follow so she put in what she felt was adequate. [NAME] #16 confirmed she pureed 21 servings of open face roast beef sandwiches for 14 residents (#3, 21, 89, 114, 164, 200, 232, 250, 300, 364, 377, 381, 383 and 384) who resided on unit A, D1 and D2, 2 North, B, C, D and 1 North. [NAME] #165 further confirmed she used a total of eight pieces of bread for the 21 servings of pureed open face roast beef sandwiches. Interview on 10/23/19 at 9:23 A.M., Food Services Supervisor #550 confirmed each serving of open faced roast beef sandwiches should have had one slice of bread for each serving. Interview on 10/24/19 at 2:19 P.M., Director of Food Services (DFS) #560 confirmed each serving of open faced roast beef sandwiches should have had one slice of bread for each serving. DFS #560 further confirmed the facility could not find a recipe for open faced roast beef sandwiches for pureed diets. The facility was unable to provide a policy directly related to preparing pureed diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 7 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of a facility policy, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents who resided in the facility except Resident #150 who was identified by the facility to not receive meals from the kitchen. The facility census was 390. Findings include: Observation of food storage on 10/23/19 at 8:56 A.M., revealed a plastic scoop was stored inside of a cardboard box of a powdered thickening agent (a substance which can increase the viscosity of a liquid). Interview on 10/23/19 at 9:21 A.M., [NAME] #165 verified a plastic scoop was stored inside the cardboard box of a powdered thickening agent. Observation on 10/23/19 at 10:07 A.M., revealed a plastic scoop was stored inside of a plastic bin of brown sugar. Interview on 10/23/19 at 10:08 A.M., Food Services Supervisor #550 verified a plastic scoop was stored inside the plastic bin of brown sugar. Review of a facility policy titled, Dry Storage, most recent revision date 07/11/18, revealed container with tight fitting covers were to be used for storing sugars, cereal, grain products and broken lots of bulk food. Further review revealed scoops were not to be stored directly in the product in the storage bins. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 8 of 8