Health inspection·September 10, 2025

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure laboratory (lab) values were completed as ordered by the physician. This affected two (#01 and #44) out of three residents reviewed for labs being completed as ordered by the physician. The facility census was 58. Findings include: 1. Review of Resident #01's chart revealed the resident was admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, pressure ulcer to the left buttock unspecified stage, pressure ulcer to the right buttock unspecified stage, traumatic subdural hemorrhage without loss of consciousness, type two diabetes mellitus and cerebral atherosclerosis. Review of Resident #01's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #01 required set up assistance with eating, and oral hygiene. Resident #01 required moderate assistance with toileting, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, sitting to standing, chair transfers, toilet transfers, tub transfers and walking ten feet and supervision with lying to sitting. Resident #01 required maximal assistance with showering. Review of Resident #01's care plan initiated on 07/21/25 revealed the facility will obtain and monitor lab and diagnostic work as ordered. Review of Resident #01's progress note dated 08/26/25 at 11:54 A.M. revealed the Wound Care Nurse Practitioner (WCNP) was in the facility to see Resident #01 and gave orders for a complete blood count (CBC), complete metabolic panel (CMP), albumin, prealbumin, transferrin and hemoglobin A1c labs. Resident #01 and Resident #01's responsible party were aware. Review of Resident #01's physician order dated 08/26/25 revealed Physician #800 created a telephone order that stated the WCNP was in the facility to see Resident #01 and gave orders for a CBC, CMP, albumin, prealbumin, transferrin and hemoglobin A1c labs. Review of Resident #01's chart from 08/26/25 to 09/10/25 revealed Resident #01's CBC, albumin, prealbumin, transferrin and hemoglobin A1c lab results ordered on 08/26/25 were not on file at the facility. Review of Resident #01's lab results report dated 08/28/25 revealed the Resident #01's CMP was completed. Interview with the Director of Nursing (DON) on 09/10/25 at 2:00 P.M. verified Resident #01 was ordered a CBC, CMP, albumin, prealbumin, transferrin and hemoglobin A1c labs on 08/26/25 by the WCNP. The DON verified the facility received Resident #01's CMP but Resident #01's CBC, CMP, albumin, prealbumin, transferrin and hemoglobin A1c labs ordered on 08/26/25 were not obtained. 2. Review of Resident #44's chart revealed Resident #44 admitted to the facility on [DATE] with unspecified pseudobulbar affection, attention and concentration deficit following cerebral infarction, depression, Alzheimer's disease, type two diabetes mellitus with unspecified complications, hyperlipidemia, hypertension, anxiety disorder, chronic kidney disease stage two and other cerebrovascular disease. Review of Resident #44's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #44 required set up assistance with eating. Resident #44 required moderate assistance with oral Residents Affected - Few Page 1 of 2 365652 365652 09/10/2025 Cottingham Retirement Community 3995 Cottingham Drive Cincinnati, OH 45241

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hygiene, upper body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, lying to sitting, chair transfers, tub transfers and walking ten feet and maximal assistance with toileting, and lower body dressing. Resident #44 was dependent with showering and supervision with sitting to lying, sitting to standing, and toilet transfers. Review of Resident #44's care plan initiated on 08/12/25 revealed the facility will obtain and monitor lab and diagnostic work as ordered. Review of Resident #44's progress note dated 07/24/25 at 4:17 P.M. revealed Resident #44 received new orders for several labs on Monday 07/28/25. Resident #44's family was notified. Review of Resident #44's physician order dated 07/24/25 revealed Physician #800 ordered Resident #44 a complete blood count (CBC), complete metabolic panel (CMP), thyroid stimulating hormone (TSH), A1c, lipid panel, ferritin, B12 and vitamin D to be collected the next lab day on 07/28/25. Review of Resident #44's chart from 07/24/25 to 09/10/25 revealed Resident #44's CBC, CMP, TSH, lipid panel, ferritin, B12 and vitamin D labs that were ordered to be collected on 07/28/25 were not on file. Interview with the DON on 09/10/25 at 2:00 P.M. verified Resident #44's CBC, CMP, TSH, lipid panel, ferritin, B12 and vitamin D labs that were ordered to be collected on 07/28/25 were not collected or obtained by the facility. Review of the facility's clinical protocol and diagnostic test results policy dated November 2018 revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. Staff will process test requisitions and arrange for testing. The laboratory will report the test results to the facility. This deficiency represents non-compliance investigated under Complaint Number 2602837. 365652 Page 2 of 2