Health inspection·August 1, 2019

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview, record review, and review of the facility's Care Planning Policy, the facility failed to provide one of 36 sampled residents, (Resident (R) 564), and their representative with a baseline care plan, or a written baseline care plan summary. The facility also failed to ensure R564's baseline care plan included a pertinent medical condition, and that it addressed the resident's overall goal and expectation to return to community living. Findings include: Review of R564's electronic and paper medical records documented the facility admitted the resident on 11/23/18 and re-admitted her on 06/27/19 and 07/24/19 with diagnoses that included type II diabetes. Review of the resident's dually-coded 5-day/admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/19, revealed R564 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated her cognitive skills were intact, and that her active diagnoses included diabetes. The Assessment and Goal Setting section of the MDS indicated the resident participated in the assessment; however, it did not specify whether the resident expected to be discharged to the community, remain in the facility, be discharged to another facility, or if the resident was undecided at the time of the assessment. Review of R564's baseline care plan, dated 07/25/19, documented under, Initial Goals, the resident would, Remain LTC [long term care]. However, a review of the Interdisciplinary Team Care Conference Note, dated 07/25/19, documented that R564, Would like to return home. Further review of the baseline care plan revealed it did not address R564's type II diabetes or the diabetic care she would require during her stay at the facility. The section of the baseline care plan titled, Written Summary of Baseline Care Plan was blank, and provided no indication the staff provided R564 and her representative with a written summary her baseline care plan, or discussed the care plan with them. During an interview on 07/31/19 at 11:44 AM, the MDS Coordinator stated, The diabetes section on the baseline care plan was missed. During an interview on 07/31/19 at 11:50 AM, the Social Service Director (SSD) noted that R564's baseline care plan was checked for LTC (long-term care). The SSD stated that she thought the resident wanted to return to the community. The SSD also stated that a copy of the baseline care plan is offered to the resident and their representative, and if neither want the care plan, she does not give them a copy. The SSD stated she does not document offering a resident their baseline care plan, nor a written summary of the baseline care plan. (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 4 Event ID: 365447 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 365447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookview Healthcare Center 214 Harding Street Defiance, OH 43512 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)