Health inspection·February 8, 2024

F 0641 Ensure each resident receives an accurate assessment. 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, interview, and facility policy review the facility failed to ensure Minimum Data Set (MDS) assessments were accurate regarding resident vaccination status. This affected three residents (#28, #38, and #99) out of five residents reviewed for vaccinations. The facility census was 107. Residents Affected - Few Findings Include: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, encephalopathy, anxiety disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 was not offered the influenza vaccine. Further review of Resident #28's medical record revealed that she was offered and received the influenza vaccine on 10/17/23. Interview on 02/08/24 at 2:42 P.M. with MDS Licensed Practical Nurse (LPN) #313 verified that Resident #28's quarterly MDS was coded incorrectly. MDS/LPN #313 modified the MDS to reflect that Resident #28 was given the influenza vaccine as requested on 10/16/23. 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, and hypokalemia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #38 was up to date on the influenza vaccine. The MDS was dated 10/11/22 as up to date on the influenza vaccine. Further review of Resident #28's medical record revealed that she was offered and received the influenza vaccine on 10/17/23. Interview on 02/08/24 at 2:42 P.M. with MDS/LPN #313 verified that Resident #38's comprehensive MDS was coded incorrectly. MDS/LPN #313 modified the MDS to reflect that Resident #28 was given the influenza vaccine as requested on 10/16/23. 3. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, major depressive disorder, dementia, and dysphagia. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #99 was up to date on the influenza vaccine. The MDS was dated 10/11/22 as up to date on the influenza vaccine. (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: 365317 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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)