Health inspection·October 12, 2022

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to complete a baseline care plan for one (Resident #262) out of the two residents reviewed for baseline care plans. The facility census was 62. Findings include: Review of the medical record for Resident #262 revealed an admission date of 09/30/22. Diagnoses included nondisplaced fracture of right femur, urinary tract infection, encephalopathy, wedge compression fracture of unspecified lumbar vertebra, diabetes mellitus, chronic atrial fibrillation, and chronic kidney disease. Review of the Nurse Designee Functional assessment dated [DATE] revealed Resident #262 required substantial/maximal staff assistance for eating, oral hygiene, and toilet hygiene. Resident #262 did not walk or transfer at the time of the assessment. Further review of the medical record revealed a Brief Interview for Mental Status dated 10/03/22 which revealed the resident had moderate cognitive impairment. Further review of the medical record revealed no documentation to support a 48-hour baseline care plan was developed and reviewed with the resident or the resident's representative Interview on 10/04/22 at 11:15 A.M. with the Director of Nursing (DON) confirmed Resident #262 did not have documentation to support a 48-hour care plan was completed and reviewed with resident or resident's representative. Review of facility policy titled, Baseline Care Plan, stated the facility is to complete Baseline Care Plan to promote the continuity of care and communication among nursing home stakeholders, increase resident safety, and safeguard against adverse events that most likely to occur right after admission. Further review of the policy revealed the 48-hour baseline care plan would be the working tool for the for the first 48 hours and would be presented to resident and/or representative prior to completion of Comprehensive Care Plan. The policy stated the facility must provide a summary of the care plan to the resident and/or representative. 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: 365679 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 365679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160 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)