Inspection·October 3, 2019

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 observation, record review and staff interviews, the facility failed to accurately code information on the Minimum Data Set (MDS) assessments. This affected two (#2 and #12) of 23 residents reviewed for MDS accuracy in the final sample. The facility census was 101. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 06/16/18. Diagnoses included dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and indicated Resident #2 had impairment in functional limitations for both sides of upper and lower extremities. Observation on 10/02/19 at 2:09 P.M. revealed Resident #2 participating in activities. She was observed walking in the common area, drinking juice, flipping pages of a magazine and smacking her hands on a table for attention. There were no functional limitations observed with the resident's upper extremities. Interview with MDS Licensed Practical Nurse (LPN) #37 on 10/03/19 at 1:55 P.M. reported Resident #2 was not cooperative with her, so she coded impairment. When questioned what the specific functional impairment was that she had observed, LPN #37 stated the resident could not move things like her toes. LPN #2 stated she was unaware of any specific functional impairment for Resident #12. Interview with Unit Manager #37 on 10/03/19 at 2:45 P.M. verified she completed the functional resident observations form on 03/21/19 and 06/21/19 for Resident #12 as no impairment. She reported the forms were completed for MDS completion. She stated Resident #2 was able to do the activities she wanted, feed herself, transfer and ambulate independently, and pick up objects. 2. Review of the medical record for Resident #12 revealed an admission date of 06/06/19. Diagnoses included vascular dementia with behavioral disturbance, osteoarthritis and presence of artificial knee joint left and right. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #12 had cognitive impairment and had functional limitations on both sides of lower extremities and no impairment of upper extremities. Review of the physical function observation form, dated 07/09/19, indicated Resident #12 had no (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: 365480 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 365480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Salem Woods 6164 Salem Road Cincinnati, OH 45230 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)