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. (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 2 Event ID: 365202 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 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 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)