Inspection·August 8, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure a potential incident of physical abuse was immediately reported to the Administrator and to the State agency as required. This affected two residents (#7 and #8) of two residents reviewed for abuse. Findings include: Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hypertensive chronic kidney disease, acute cystitis, osteoarthritis, atherosclerosis, atherosclerotic heart disease, vascular dementia without behavioral disturbances, anxiety disorder, restlessness and agitation, major depressive disorder, and hypothyroidism. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 revealed the resident had significant cognitive impairment. Review of Resident #7's progress notes, dated 07/10/22 (late entry written on 07/11/22), revealed the nurse was passing medication and heard yelling from the dining area. She went to the dining area and found Resident #7 yelling and trying to hit Resident #8. Resident #8 stated Resident #7 came from behind her and hit her left eye. Nurse confirmed she assessed her eye and found a red mark near the left eye of Resident #8. Both residents were separated and staff sat one on one with Resident #7 until she went to sleep. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances, hypertensive heart disease, congestive heart failure, anemia, hyperlipidemia, restless leg syndrome, low back pain, depression, anxiety disorder, mood disorder, insomnia, osteoporosis, hearing loss, abnormalities of gait and mobility, and muscle weakness. Review of the MDS 3.0 assessment, dated 05/13/22 revealed the resident had moderate cognitive impairment. Review of Resident #8's progress notes, dated 07/10/22 revealed the nurse was told by Resident #8 that another resident (Resident #7) hit her on the face. On 08/04/22 at 2:42 P.M. interview with the Administrator revealed the incident between Resident #7 and Resident #8 was not reported to her until 07/11/22, when law enforcement entered the facility to start an investigation and take a report. She confirmed documentation supported Resident #8 reported to facility staff she was hit by Resident #7 in the eye, and there was a red mark near that eye. She confirmed documentation supported this occurred and facility staff knew about the incident on 07/10/22. She confirmed an allegation of physical abuse was not reported to the State agency until 07/11/22. Review of facility Abuse, Neglect, and Exploitation Procedural Guidelines, dated 08/29/19, revealed the definition of abuse was the willful infliction of injury. The policy indicated the facility was to ensure all alleged violations involving abuse were reported immediately, but no later than two hours after the allegation was made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 2 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to provide a bed hold notice to Resident #42 and/or the residents representative at the time of discharge to the hospital. This affected one resident (#42) of two residents reviewed for hospitalization. Findings include: Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, respiratory failure, hypertensive heart and kidney failure, congestive heart failure, atrial fibrillation, morbid obesity, osteoarthritis, obstructive sleep apnea, type II diabetes, hyperlipidemia and dependence on supplemental oxygen. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22 revealed the resident was cognitively intact. Review of Resident #42's medical record revealed she was discharged from the facility to the hospital on [DATE]. Record review revealed no evidence the resident or her responsible party were provided a bed hold notice at the time of discharge. On 08/04/22 at 8:34 A.M. interview with Director of Social Services (SS) #175 revealed the business office staff provided bed hold notices for those residents' who received Medicaid. SS #175 revealed per their regional office, the facility did not have to provide a bed hold notice for residents' who were not on Medicaid. Resident #42 was not on Medicaid. SS #175 verified a bed hold notice was never provided to Resident #42 or her representative at the time of discharge. Federal requirements require bed hold information to be provided to all facility residents, regardless of their payment source. Review of the facility Bed Hold policy, dated 11/23/16 revealed for Medicare residents who were transferred to the hospital, and upon notification of the discharge, the resident or representative would be asked if they would like their bed held. If they do, the bed would be reserved at the basic rate and billed privately until the resident/responsible party notified the campus they no longer want to reserve the bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 3 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 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 observation, record review and interview the facility failed to ensure Resident #243's peripherally inserted central catheter (PICC) line dressing was changed as ordered by the physician. This affected one resident (#243) of two residents reviewed for intravenous catheter lines. Residents Affected - Few Findings include: Record review revealed Resident #243 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of right great toe, osteomyelitis, cellulitis of right lower limb, type two diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy and chronic obstructive pulmonary disease. Record review revealed a physician's order, dated 07/08/22 for IV- PICC dressing change every five days, measure external catheter length, enter in measurement med note. Review of the 07/15/22 admission Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact and required extensive assistance from staff for transfers and limited assistance from staff for bed mobility, dressing, toilet use and personal hygiene. The assessment revealed the resident used a wheelchair to aid in mobility, had an indwelling urinary catheter, was occasionally incontinent of bowel and received intravenous (IV) medications. On 08/02/22 at 9:50 A.M. Resident #243 was observed with a PICC line dressing to his right upper arm. The dressing was dated 07/24/22. On 08/02/22 at 9:50 A.M. interview with Resident #243 revealed it had been about a week since staff had changed his PICC line dressing. On 08/02/22 at 10:17 A.M. interview with Registered Nurse (RN) #125 verified Resident #243's PICC line dressing was dated as last being changed on 07/24/22 (nine days prior). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 4 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure pre and post hemodialysis assessments were completed for Resident #14. This affected one resident (#14) of one resident reviewed for hemodialysis. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/29/22 with diagnoses including encephalopathy, end stage renal disease with dependence on renal dialysis, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, hyperlipidemia, gastro-esophageal reflux disease, disorientation, and unspecified convulsions. Review of the physician's orders, dated 05/30/22 to 06/01/22 revealed an order for hemodialysis every Monday, Wednesday and Friday. A Dialysis Center Communication Observation was to be completed under 'other clinical observation' and sent with the resident. On 06/01/22 a physician's order revealed hemodialysis every Monday, Wednesday and Friday. A Dialysis Center Communication Observation was to be completed under 'other clinical observation' and sent with resident. Dialysis was scheduled at Fresnius in Pickerington 12:00 P.M. to 4:00 P.M. Review of the plan of care, dated 06/09/22 revealed Resident #14 had renal failure resulting in the need for (hemo) dialysis. Interventions included assessing the access site for signs of infection, coordinating care with the dialysis center, diet and fluid restrictions according to orders, observing catheter site according to orders, observing for signs of systematic infection and treatment to dialysis site per physician's order. Review of the electronic observation documentation from 05/29/22 to 07/27/22 revealed pre-dialysis and post-dialysis assessments were not completed for every dialysis session: On 06/01/22 no pre or post dialysis assessment was completed. On 06/03/22 a dialysis communication form was completed prior to dialysis only. On 06/06/22, 06/08/22, 06/10/22, 06/13/22, 06/15/22, 06/17/22, 06/20/22 and 06/24/22, no pre or post dialysis assessment was completed. On 06/24/22 a dialysis communication form was completed prior to dialysis only. On 06/29/22, 07/01/22, 07/04/22, 07/06/22, 07/08/22, 07/11/22, 07/13/22, 07/15/22, 07/18/22, 07/20/22, 07/22/22, 07/25/22 and 07/27/22 no pre or post dialysis assessment was completed. Review of the medical record from 05/29/22 to 07/27/22 revealed nothing to indicate Resident #14 had missed any dialysis appointments during this time period. On 08/03/22 at 11:19 A.M. interview with Licensed Practical Nurse (LPN) #163 revealed dialysis assessments were to be completed before and after dialysis. The LPN revealed the assessments were one form that was opened (electronically) in the morning but not completed until the resident returned from the dialysis center. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 5 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0698 Level of Harm - Minimal harm or potential for actual harm On 08/04/22 at 4:23 P.M. and 5:00 P.M. interview with Clinical Support Registered Nurse (RN) #207 revealed assessments were to be completed before and after dialysis. Clinical Support Registered Nurse #207 confirmed the assessments were not being completed for Resident #14 for all of his dialysis treatments as noted above. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 6 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 12.90% and included four medication errors of 31 medication administration opportunities. This affected one resident (#293) of three residents observed for medication administration. Residents Affected - Few Findings include: Record review revealed Resident #293 was admitted to the facility on [DATE] with diagnoses including moderate protein-calorie malnutrition, atherosclerosis of aorta, asthma, hyperlipidemia, irritable bowel syndrome without diarrhea, dysphagia, dysphonia, adult failure to thrive, hypertension, gastro-esophageal reflux disease, constipation and shortness of breath. Review of physician's orders revealed the following oral medication orders, dated 07/13/22: Aspirin tablet delayed release/ enteric coated (DR/EC) 81 milligrams (mg) oral once a day for blood thinning. Metoprolol succinate (blood pressure and angina medication) extended release 50 mg for hypertension. Pantoprazole (medication for treatment of gastro-esophageal reflux disease) delayed release 40 mg for gastro-esophageal reflux disease. Miralax (polyethylene glycol 3350) give 17 grams for constipation every day. Record review revealed an order indicating staff may crush meds or open capsules as needed unless contraindicated and referred staff to the Do not crush list. On 08/03/22 at 8:20 A.M. Registered Nurse (RN) #125 was observed administering medications to Resident #293. RN #125 obtained the resident's medication and proceeded to crush the Enteric coated Aspirin, extended release Metoprolol, and delayed release Pantoprazole before administering them in chocolate pudding to Resident #293. At the time of the observation, RN #125 verified she had administered and was completed with the medication administration for Resident #293. On 08/03/22 at 9:29 A.M. interview with RN #125 verified she crushed the Aspirin enteric coated, Pantoprazole delayed release and Metoprolol 50 mg extended release; medications that should not have been crushed for administration. RN #125 also verified she did not administer the resident her Miralax at the time of the medication administration as ordered. Review of the information provided from the Safe Medication Practices website revealed Enteric coated Aspirin, Metoprolol succinate slow release and Pantoprazole slow release were on the do not crush list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 7 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to prepare and serve pureed foods in a manner to ensure they were served at the proper temperature and to ensure palatability. This had the potential to affect two residents (#241 and #244) of two residents identified to be on a pureed diet. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #241 revealed an admission date of 06/21/22 with diagnoses including fracture of unspecified part of neck of left femur, encephalopathy, sepsis, anxiety disorder, dysphagia, adult failure to thrive, and restlessness and agitation. Resident #241 had a physician's order, dated 07/08/22 for a regular diet with a puree consistency Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22 revealed Resident #241 had intact cognition, was on a mechanically altered diet and had a feeding tube providing 51% or more of calories and 501 cubic centimeters (cc's) or more of fluid a day. Review of the medical record for Resident #244 revealed an admission date of 07/15/22 with diagnoses including atherosclerotic heart disease, end stage renal disease with dependence on renal dialysis, type two diabetes, and adult failure to thrive. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/19/22 revealed Resident #244 had severe cognitive impairment and was on a mechanically altered and therapeutic diet. Resident #244 had a physician's order, dated 07/22/22 for a no added salt, puree diet. On 08/04/22 at 11:35 A.M. Dining Services Assistant Director (DSAD) #169 was observed preparing pureed food. The meat and potatoes were prepared appropriately and portioned into two divided plates, the two divided plates were then wrapped in saran wrap and put on the food prep table under a heat lamp. On 08/04/22 at 11:35 A.M. Dining Services Assistant Director (DSAD) #169 was observed preparing the dessert, banana cream pie. DSAD #169 put three pieces of pie in a blender and added an unmeasured amount of water that appeared to be more than a tablespoon. She then added two teaspoons of thickener to the blender and began to blend the dessert. DSAD #169 peered down into the blender and then added an additional amount of unmeasured water and an additional tablespoon of thickener. The food was blended again, and then poured into bowls. It was the consistency of applesauce. Interview at that time with DSAD #169 revealed she was following the recipe for three servings. However, she then confirmed she did not follow the recipe when she used unmeasured amounts of liquid, used water instead of whole milk, and exceeded the amount of thickener in the recipe. On 08/04/22 at 12:25 P.M. observation revealed the two plates of pureed meat and potatoes remained under the heat lamp. Meal service was observed from 12:25 P.M. to 12:50 P.M., one plate of pureed food went to Resident #241 and around 12:45 P.M. staff were observed pushing a cart towards the kitchen exit to serve trays to Resident #244 and his unit. At that time DSAD #169 confirmed the last pureed food was about to be delivered to Resident #244. DSAD #169 took the temperature of the food at that time and found the meat to be 115.2 degrees and the potatoes to be 102.8 degrees. She asked staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 8 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to warm the food up as it was too cold to serve to the resident. DSAD #169 confirmed both puree plates had been sitting under the heat lamp from the time they were plated to when they were served, approximately an hour later. DSAD #169 revealed the pureed foods were usually prepared and held until service in this manner. On 08/04/22 at 10:31 A.M. interview with Resident #241 revealed his food was not always served to him hot. He additionally reported the food was not consistent in texture, which was described as being different in how it looked or felt when he ate it. Review of the recipe titled pie banana cream pureed thick, revealed the recipe for three servings included three one tenth slices of banana cream pie, one and three fourths teaspoon of whole milk, and seven eighths teaspoon of food thickener. The procedure to be followed was to place pie pieces into the food processor, add milk and process until smooth, add food thickener and process briefly until mixed. Scrape down the sides with spatula and reprocess, cover and chill before serving. The pie was to be served using a number 10 scoop per serving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 9 of 10 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #5 was provided assistive devices at meals as ordered. This affected one resident (#5) of three reviewed for nutrition. Residents Affected - Few Findings include: Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, atherosclerotic heart disease, unspecified psychosis not due to a substance or known physiological condition, delirium due to known physiological condition, other bipolar disorder, post-traumatic stress disorder, auditory hallucinations and gastro-esophageal reflux disease. Review of the physician's order revealed an order, dated 03/29/21 for Resident #5 to use a divided plate at all meals for increased ability to self-feed during meals. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/29/22 revealed Resident #5 had severe cognitive impairment and required the supervision of one staff person for eating. On 08/01/22 from 12:30 P.M. to 1:13 P.M. observation of the lunch meal revealed Resident #5's food was served on a regular plate. The resident was observed feeding herself, however she was frequently observed pushing food to the edge of her plate that subsequently fell off the plate. Resident #5 was observed picking up pieces of food that fell off her plate with her hands. On 08/02/22 at 12:30 P.M. observation of the lunch meal revealed Resident #5's food was served on a regular plate. On 08/04/22 at 12:50 P.M. observation of the lunch meal revealed Resident #5's food was served on a regular plate. Observation at 2:37 P.M. revealed Resident #5 was still feeding herself lunch. The resident was observed pushing food items against other food items to scoop them up. She was again observed pushing food off the plate and picking it up with her fingers and eating it. On 08/04/22 at 2:38 P.M. interview with Assistant Director of Health Services (ADHS) #178 confirmed Resident #5 did not have a divided plate and had an order that called for it. ADHS #178 confirmed the facility had divided plates available for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 10 of 10