Health inspection·September 19, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interviews and policy review the facility failed to develop a complete comprehensive care plan to include activities. This affected three (Resident #9, #13, and #45) out of four residents reviewed for activities. The facility census was 88. Findings include: 1. Record review of Resident #9 revealed an admission date of 07/10/23 with diagnoses of acute and chronic respiratory failure with hypoxia, major depressive disorder, and heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required set-up assistance with eating, and required supervision assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and ambulation. Review of the Activities Initial Review assessment dated [DATE] revealed the resident had interests / hobbies of arts and crafts. Unknown if resident wished to participate in activities while in the facility. Review of the current care plan revealed it was absent for activities. 2. Record review of Resident #13 revealed an admission date of 07/10/24 with diagnoses of osteoarthritis of the hip, type II diabetes mellitus without complications, and depression. Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact, required supervision assistance with eating, required substantial assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and wheelchair mobility. Review of the Activities Initial Review assessment dated [DATE] revealed the resident had interests / hobbies of word puzzles and watching television. Unknown if resident wishes to participate in activities while in the facility. Review of the current care plan revealed it was absent for activities. 3. Record review of Resident #45 revealed an admission date of 04/19/24 with diagnoses of acute osteomyelitis of right ankle and foot, acquired absence of left leg below knee, and type II diabetes mellitus with diabetic chronic kidney disease. Page 1 of 2 365186 365186 09/19/2024 Ayden Healthcare of Madeira 5970 Kenwood Road Cincinnati, OH 45243

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MDS dated [DATE] revealed resident had cognitive skills for independent decision-making skills and required set-up assistance with all activities of daily living. Review of the Activities Initial Review assessment dated [DATE] revealed resident had interests / hobbies of arts, crafts, bingo, cards, and board games. Unknown if resident wishes to participate in activities while in the facility. Review of the current care plan revealed it was absent for activities. Interview on 09/19/24 at 10:44 A.M. with Activities Director #282 confirmed the Activities Director is responsible for to completing and updating residents activity care plans. Interview also confirmed Residents #9, #13, and #45 did not have an activity care plan. Interview on 09/19/24 at 12:01 P.M. with Registered Nurse (RN) MDS Coordinator #297 confirmed Residents #9, #13, and #45 did not have an activity care plan. Review of the Care Planning policy dated 08/2021 revealed Our facility's care planning / interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by care planning / interdisciplinary team which includes, but is not necessarily limited to the following personnel: e. The activity director / coordinator. 365186 Page 2 of 2