Inspection·May 27, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure the physician signed a resident's formulated advanced directive. This had the potential to affect one resident (#7) of two residents reviewed for advanced directives. The facility census was 46. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, cognitive communication deficit, personal history of COVID19, muscle weakness, gastro esophageal reflux disease without esophagitis, essential tremors, nicotine dependence and iron deficiency anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, dressing, toileting, eating and personal hygiene. Review of the code status form revealed Resident #7's guardian requested the resident was a do not resuscitate comfort care (DNRCC) on 04/20/20. Further review of the form revealed the form had not been signed by a physician. Review of the advanced directives care plan dated 01/18/21 revealed Resident #7 was listed as a DNRCC. Interview with Social Services Director (SSD) #59 on 05/26/21 at 9:12 A.M. verified Resident #7's DNRCC code status form dated 04/20/20 was not signed by the physician in the paper chart. SSD #59 also verified Resident #7's code status was listed as a DNRCC in the electronic record. Review of the facility policy titled Advanced Directives dated December 2016 revealed the Director of Nursing (DON) or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician will not be required to write orders for which he or she has an ethical or conscientious objection. 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 9 Event ID: 365336 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 365336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Locust Ridge Healthcare LLC 12745 Elm Corner Road Williamsburg, OH 45176 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)