Health inspection·August 17, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, review of Resident Assessment Instrument (RAI) Manual 3.0, and policy review, the facility failed to conduct care plan review meetings quarterly and with significant change in residents' health status. This affected two (#4 and #9) out of the four residents reviewed for care plan meetings. The facility census was 68. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 12/05/22 with medical diagnoses of chronic kidney disease Stage III, arthritis, anemia, and heart disease. Review of the medical record for Resident #4 revealed a quarterly Minimum Data Set (MDS) 3.0, dated 07/21/23, indicated Resident #4 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing. Review of the medical record for Resident #4 revealed documentation the facility conducted a care conference on 02/09/23 with the resident, resident's daughter, and IDT. Further review of the medical record revealed no documentation to support the facility conducted a care conference since 02/09/23. Interview on 08/14/23 at 11:27 A.M. with Resident #4 stated she had not been invited or attended a care conference recently. Interview on 08/16/23 at 8:44 A.M. with Social Service Supervisor (SSS) #316 confirmed the medical record did not contain documentation to support the facility conducted a quarterly care conference for Resident #4 since 02/09/23. 2. Review of the medical record for Resident #9 revealed an admission date of 06/11/18 with medical diagnoses of Friedreich's ataxia, paraplegia, polyneuropathy, and attention to gastrostomy. Review of the medical record for Resident #9 revealed a quarterly MDS, dated [DATE], which indicated Resident #9 was cognitively intact and required extensive staff assistance with bed mobility, transfers, dressing, toileting, and was dependent for eating. Further review of the medical record revealed Resident #9 had significant change MDS assessments completed on 12/09/22 due to Resident #9 enrolled onto Hospice services and 03/07/23 due to Resident #9 discontinued Hospice services. Review of the medical record for Resident #9 revealed documentation to support 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 5 Event ID: 365627 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 365627 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Huber Heights The 5440 Charlesgate Road Huber Heights, OH 45424 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)