Health inspection·July 30, 2025

F 0791 Provide or obtain dental services for each resident. 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, staff interview, observations and policy review, the facility failed to investigate the allegation of missing dentures. This affected one Resident (#35) of three reviewed for dental appliances. The facility census was 87. Findings include:Review of the medical record for Resident #35 revealed an admission on [DATE] with diagnoses including hypertension, hemiplegia and hemiparesis following a subdural hemorrhage affecting the right side, type two diabetes mellitus and congestive obstructive pulmonary disease. Review of the physician's orders for Resident #35 revealed an order dated 09/22/23 for the resident to receive dental services. Review of the care plan for Resident #35 dated 11/06/23 and updated on 03/27/25 revealed resident was at risk for altered nutritional states related to dysphagia (difficulty swallowing), need for pureed diet, hospice care, and was edentulous with dentures. Interventions included the following: ensure dentures were utilized for meals, monitor meal intake, provide assistance with meals as needed. Review of the dental progress note for Resident #35 dated 06/24/24 revealed the resident had upper and lower dentures in place. Review of the facility personal effects inventory for Resident #35 undated revealed dentures were included on the form in the listing of the resident's possessions. Review of the progress notes for Resident #35 dated 01/01/25 to 07/29/25 revealed the notes did not include documentation of missing dentures. Review of the hospice progress note for Resident #35 dated 01/04/25 at 12:50 P.M. revealed the resident representative reported to facility Nurse #94 the resident's lower denture was missing. Review of the hospice progress note for Resident #35 dated 02/03/25 at 10:47 A.M. revealed the resident's lower denture was not in her mouth and the denture was lost. Review of the dental progress note for Resident #35 dated 03/11/25 revealed the resident had a dental exam with no concerns. The upper denture was in place, but the lower denture was not in place at the time of the visit. Review of the facility grievance log dated 05/01/25 to 07/28/25 revealed there was no documentation regarding missing dentures.Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 05/09/25 revealed the resident had impaired cognition, required extensive assistance with activities of daily living (ADLs), and was edentulous.Review of the nutritional assessment for Resident #35 dated 06/27/25 revealed the assessment did not include documentation regarding the resident's missing lower denture. Review of the facility grievance log dated 05/01/25 to 07/28/25 was silent for any documentation of missing dentures. Observation on 07/29/25 at 2:50 P.M. of Resident #35 revealed the resident's lower denture was not in place. Interview on 07/29/25 at 2:51 P.M. of Resident #35 confirmed her lower denture had been missing for approximately eight months. Resident #35 reported the facility staff and hospice staff were notified the denture was missing and she had not heard of any plans for replacement of the lower denture. Interview on 07/29/25 at 1:28 P.M. with Mobile Dentist Office Staff (MDOS) #109 confirmed the dental progress note for Resident #35 dated 03/11/25 indicated the resident did not have her lower denture on the day of the exam. MDOS #109 confirmed there were had been prior authorization submitted for denture replacement for Resident #35 and Residents Affected - Few Page 1 of 4 365178 365178 07/30/2025 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dental notes did not include documentation of the resident's lower denture being reported as missing. Interview on 07/29/25 at 1:47 P.M. with Certified Nursing Assistant (CNA) #47 confirmed Resident #35's lower denture had been missing for a long time, and she denied any knowledge of plans for replacement. CNA #47 stated she was unsure of who she notified regarding Resident #35's missing lower denture as it was months ago. Interview on 07/29/25 at 2:11 P.M. with Registered Nurse (RN) #91 confirmed Resident #35's lower denture had been missing for an undetermined amount of time, and RN #91 denied knowledge of plans for replacement. Interview on 07/30/25 at 12:27 P.M. with Hospice Executive Director ([NAME]) #113 confirmed Resident #35 had stated the missing denture was reported to the facility by hospice staff. [NAME] #113 confirmed hospice staff documented in Resident #35's progress notes the missing denture was reported to the hospice case manager on 01/04/25. Interview on 07/30/25 at 3:19 P.M. with the Administrator confirmed the facility management was never notified of Resident #35's missing denture. Review of the facility policy titled Dental Services undated revealed the facility would promptly (within three days) refer residents with lost or damaged dentures for dental services. This deficiency represents noncompliance investigated under Complaint 2572145. 365178 Page 2 of 4 365178 07/30/2025 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospice documentation, staff interview, hospice staff interview, review of the contract between the hospice provider and the facility, and review of the facility policy, the facility failed to ensure collaboration between the hospice provider and the facility was documented in the medical record. Additionally, the facility failed to retain copies of hospice provider progress notes at the facility. This affected two (Residents #35 and #7) of three residents reviewed for hospice services. The facility census was 87 residents. Findings include:1.Review of the medical record for Resident #35 revealed an admission date of 09/22/23 with diagnoses including hypertension, hemiplegia and hemiparesis following a subdural hemorrhage affecting the right side, type two diabetes mellitus and congestive obstructive pulmonary disease. Review of the facility plan of care for Resident #35 dated 09/28/23 and revised on 07/25/25 revealed resident had an activities of daily living (ADL) self-care performance deficit related to cognitive and functional deficits and disease progression. Interventions included the following: provide set up assistance for eating, maximal assist for oral hygiene, resident is dependent for toileting, bathing, dressing, and personal hygiene. The facility plan of care did not include specified tasks each provider would complete. Review of the facility plan of care for Resident #35 dated 11/15/23 and revised on 01/27/25 revealed the resident received hospice services related to vascular disease. Interventions included the following: adjust level of ADL assistance to compensate for residents changing ability, encourage participation, administer medications as ordered, report abnormal findings, assure the resident and resident representative are involved in the development of goals and treatment plan, pain evaluation, expression of feelings, invite hospice staff to care conferences, offer emotional support. Review of the physician's orders for Resident #35 revealed an order dated 01/03/25 to admit the resident to hospice services.Review of the hospice plan of care for Resident #35 dated 03/03/25 revealed the nurse would visit one to two times a week and the home health aide (HHA) would visit one to two times a week. Review of the home health aide (HHA) care plan with a start of care for Resident #35 dated 03/04/25 through 05/02/25 revealed the HHA would provide the following services with every visit one to two times per week: turning and repositing in bed, assistance with feeding, bathing, shampoo, skin care, apply moisturizer, perineal care apply barrier, cream to intact skin, oral care, offer fluids, provide conversation. There was no updated HHA care plan in place during the survey. Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 05/09/25 revealed the resident had impaired cognition, required extensive assistance with activities of daily living (ADLs), and received hospice services. Review of the hospice binder for Resident #35 revealed it did not include documentation of hospice visits, assessments completed, HHA visits and care provided.2. Review of the medical record for Resident #7 revealed an admission date of 12/24/21 with diagnoses including extrapyramidal and movement disorders, type two diabetes, hypertension, and adult failure to thrive.Review of the MDS assessment for Resident #7 dated 05/16/25 revealed the resident had impaired cognition, was coded as dependent on staff for ADLs, and received hospice care during the assessment period. Review of the physician's orders for Resident #7 revealed an order dated 05/26/25 to admit to hospice services. Review of the care plan for Resident #7 dated 06/23/25 revealed the resident received hospice services for cerebrovascular disease. Interventions included the following: decrease pain, adjust ADL assistance to compensate for changing abilities, medications as ordered, pastoral care as needed, coordinate care with hospice agency, invite hospice staff to care conference, offer nonpharmacological interventions as needed. Review of the hospice binder for Resident #7 revealed it 365178 Page 3 of 4 365178 07/30/2025 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not include documentation of hospice visits, assessments completed, HHA visits and care provided. Interview on 07/28/25 at 4:25 P.M. with Hospice Registered Nurse (HRN) #112 confirmed the hospice agency receptionist was supposed to print hospice notes so the field staff could put them in the facility binder. HRN #112 verified the agency receptionist had stopped printing the hospice notes for the field staff since December 2024. Interview on 07/29/25 at 10:34 A.M. with the Social Service Director (SSD) confirmed she was the point of contact for the facility in regards to the hospice patients. The SSD stated hospice and facility staff met monthly but do not document or address the plan of care specifically. The SSD verified she did not develop or update the hospice plan of care for the facility. The SSD stated the facility had all participants sign a signature sheet when care conferences occurred but denied any conversations related to the plan of care specifically addressing services each provider would perform and when the care would be scheduled. Interview on 07/29/25 at 1:47 P.M. with Certified Nurse Assistant (CNA) #47 confirmed she was not aware of any care scheduled for Resident #35 or Resident #7 to be completed by hospice staff. CNA #47 stated she provided Resident #35 a bed bath every day that she was assigned to the resident per the resident representative request. CNA #47 stated hospice staff usually arrive after the bed bath was provided by the facility staff. CNA #47 denied any knowledge of hospice documentation for care provided for Resident #35 or Resident #7 or a schedule for days they would be providing care. Interview on 07/29/25 at 2:41 P.M. with Registered Nurse (RN) #91 assigned to both Resident #35 and Resident #7 verified there was no documentation of hospice visits in the residents' medical records when the hospice CNA or nurse visited. RN #91 stated the hospice nurse would share the vital signs obtained during the visit but did not know the location of hospice documents detailing the visit. Interview on 07/30/25 at 10:58 A.M. with the Director of Nursing (DON) confirmed the facility did not have documentation of hospice visits and care provided for Residents #7 and #35. Interview on 07/30/25 at 11:34 A.M. with Hospice Executive Director ([NAME]) #113 confirmed the hospice documentation for Residents #35 and #7 were emailed to the facility DON on 07/30/25 as it was reported the facility did not have any progress notes in the hospice binders for the residents. Interview on 07/30/25 at 4:59 P.M. with MDS Nurse #33 confirmed she had not collaborated with hospice staff for the development of the care plans for Residents #35 and #7 and the care plans did not include the specific tasks each provider would be performing for Resident #35 and Resident #7. Review of the hospice agency contract with the facility dated 2025 revealed the hospice and the facility should develop and maintain a written plan of care. The plan of care should identify which provider was responsible for performing the respective functions that had been agreed upon and included in the resident care plan. The care plan should be reviewed and updated every fifteen days or sooner when there were changes in the hospice residents' condition. The hospice and the facility should communicate with each other regularly and each party was responsible for documenting such communication in each resident's clinical record to ensure the needs of the hospice care were met. Review of the facility policy titled Coordination of Care for Hospice Services undated revealed the facility and hospice service would develop a coordinated clinical plan of care that was specific for each resident receiving hospice services within the facility. This deficiency represents noncompliance investigated under Complaint 2572145. 365178 Page 4 of 4