Health inspection·December 18, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policy, the facility failed to ensure the medical record contained accurate documentation regarding resident monitoring. This affected one (#14) of three residents reviewed for monitoring. The facility census was 67. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/03/23 with diagnoses of encephalopathy, chronic pancreatitis, and need for assistance with personal care. Further review revealed Resident #14 was admitted to the hospital on [DATE] and remained out of the facility at the time of the survey conducted 12/18/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition and did not exhibit physical, verbal, or other behaviors. Further review revealed Resident #14 was not on an anticoagulant. Continued review revealed Resident #14 received scheduled and as-needed pain medication. Review of the physician orders for Resident #14 revealed an order dated 12/01/23 to Monitor Behavior using the behavior tool as a guide for documenting B: Behavior, I: Intervention, O: Outcome every shift. Review of a physician order dated 12/01/23 revealed Resident #14 should receive monitoring for anticoagulant/anti-platelet (blood thinners) medication every shift. Instructions included document by initialing - if monitored and none of the above signs/symptoms were noted. Review of the Medication Administration Record (MAR) for December 2023 revealed agency staff documented monitoring of behaviors and anti-coagulant side effects for Resident #14 on the evening of 12/17/23. Interview on 12/18/23 at 9:04 A.M., with the Assistant Director of Nursing (ADON) revealed Resident #14 was at the hospital. Interview on 12/18/23 at 2:25 P.M., with the Director of Nursing (DON) revealed Resident #14 was hospitalized from [DATE] through the time of the survey. Continued interview with the DON confirmed staff documented Resident #14 was monitored for behaviors and anti-coagulant side effects on 12/17/23 while Resident #14 was out of the facility. Page 1 of 2 365202 365202 12/18/2023 Carecore at Lima 599 South Shawnee Street Lima, OH 45804

F 0842 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled, Charting and Documentation, revised 07/2017, revealed documentation in the medical record will be objective, complete, and accurate. This deficiency represents non-compliance investigated under Complaint Number OH00148927 and is an example of continued noncompliance from the survey dated 12/04/23. Residents Affected - Few 365202 Page 2 of 2