Health inspection·July 30, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, review of the medical record, staff interview, and review of the facility's policy, the facility failed to treat residents with dignity by hanging a sign with resident care needs on the wall near the resident's bed. This affected one (#21) of two residents reviewed for dignity. The facility census was 66. Findings include: Review of Resident #21's medical record revealed an admission date of 11/30/16. Diagnoses included dementia with behavioral disturbance, other intervertebral disc degeneration lumbar region, major depressive disorder, anxiety disorder, generalized muscle weakness, difficulty walking, and unspecified lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 07/06/21, revealed Resident #21 was severely cognitively impaired and required extensive assistance to total dependence with activities of daily living. Observation on 07/26/21 at 11:04 A.M. revealed a sign hanging on the wall near Resident #21's bed. The sign stated, For (Resident's name) transfers: Please use the steady with two assistance, must use gait belt. Please ask (Resident's name) to bend her knees when placing the steady in front of her. Use a gait belt to lift her up, don't pull on arms, she will not be using her arms to help you lift. You must completely assist her to stand. She is an extensive two assist with gait belt. Please keep the cup holder near her to allow her to drink without assistance. A second sign stated Please put the splint on her right hand. She is to wear that during the day. Two photographs, without Resident #22's face featured, were posted near the signage. Interview on 07/27/21 at 3:06 P.M. with Licensed Practical Nurse (LPN) #405 verified Resident #22's care plan instructions with pictures were posted on the wall near the resident's bed. Review of the facility's policy titled Resident Right Guidelines, revised 05/11/17, verified residents have the right to be treated with dignity and respect. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 366423 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 366423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Ottawa The 147 Putnam Parkway Ottawa, OH 45875 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)