Health inspection·January 8, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, resident interview, staff interview and review of facility training, the facility failed to ensure passive range of motion (PROM) was completed as ordered. This affected one (#1) of three residents reviewed for range of motion. The facility census was 83. Findings include: Review of Resident #1's medical record revealed an admission date of 09/25/19. Diagnoses included acute respiratory failure, quadriplegia, emphysema, heart disease with heart failure, dysphagia, post-traumatic stress disorder, anxiety disorder, personality disorder, and delirium. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact. Resident #1 had impaired upper and lower extremities. Resident #1 required extensive assistance with bed mobility, transfer, and toilet use. Resident #1 displayed rejection of care behaviors one to three days during the review period. Review of Resident #1's care plan revised 11/09/23 revealed supports and interventions for risk for decline of range of motion. Resident #1's goal was for Resident #1 to tolerate passive range of motion to all extremities without signs and symptoms of pain. Interventions included observe for any presence of pain during ROM twice a day between 6:00 A.M. to 2:00 P.M. and 6:00 P.M. and 10:00 P.M., provide passive ROM to upper and lower extremities twice a day between 6:00 A.M. to 2:00 P.M. and 6:00 P.M. and 10:00 P.M., and provide rest periods as needed. Review of Resident #1's physician orders revealed an order dated 11/29/23 for Passive Range of Motion (PROM) to bilateral upper and lower extremities twice a day. Review of Resident #1's Physical Therapy (PT) Discharge paperwork dated 11/21/23 revealed discharge recommendations of Range of Motion twice a day. Review of Resident #1's Occupational Therapy (OT) Discharge paperwork dated 11/30/23 revealed State Tested Nursing Assistants (STNA) #208, #205, #212 and #207 were trained on Resident #1's bilateral upper extremity passive range of motion exercises. Resident #1 was discharged from OT due to exhausting his benefits and declined treatment. Review of Resident #1's Passive Range of Motion (PROM) documentation from 12/01/23 through 12/31/23 revealed Resident #1 was not provided PROM on first shift 19 out of the 31 days. ROM was not (continued on next page) 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 2 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 01/08/2024 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)