Health inspection·December 6, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and policy review, the facility failed to provide residents with assistance with activities of daily living (ADL) including oral care and/or bathing services. This affected two (#30 and #35) out of six residents reviewed for ADL/personal hygiene. Facility census was 42. Residents Affected - Few Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include displaced fracture of base of neck of right femur, cerebral ischemia, celiac disease, anxiety disorder, aphasia, and unspecified nausea with vomiting. Review of the admission minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact, had no behaviors, and required assistance from staff for ADL's. Interview with Resident #30 on 12/05/23 at 11:40 A.M. revealed the resident stated she was supposed to have a shower the day before but it did not happen and she could not remember why. Resident #30 stated she had not had any assistance to clean her teeth since her admission on [DATE]. Observation of Resident #30's room and interview with state tested nursing assistant (STNA) #355 on 12/05/23 at 11:50 A.M. confirmed there were no supplies (toothbrush, toothpaste mouth wash, or emesis basin) in the room or bathroom to brush the Resident #30's teeth. STNA #355 verified Resident #30 was on her assignment and she had not provided oral care to the resident on this day. STNA #355 verified there were no supplies in Resident #30's room for providing oral care to the resident. While in the room with STNA #355, Resident #30 asked why she did not get her shower on the day before and STNA #355 stated you did not feel well and did not want the shower and we washed you up in bed instead, the resident replied oh that's right. STNA #355 verified Resident #30's teeth had not been brushed on the prior day. Interview with STNA #315 on 12/06/23 at 11:10 A.M. confirmed oral care should be provided every morning to the residents, and showers are provided twice weekly or as desired by the resident. 2. Review of Resident #35's medical record revealed 35 the resident was admitted [DATE]. Diagnoses include traumatic subarachnoid hemorrhage without loss of consciousness, diffuse traumatic brain injury, protein calorie malnutrition, obesity, dementia, and type two diabetes. Review of the admission MDS dated [DATE] revealed the resident was cognitively impaired, had no behaviors required assist from staff for ADL's. (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 4 Event ID: 366492 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 366492 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwich Springs Health Campus 4680 Library Way Hilliard, OH 43026 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)