Inspection·January 9, 2020

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 medical record review, review of facility policy and staff interview, the facility failed to timely develop the resident's care plans. This affected three (Resident #41, #64 and #71) of 24 residents reviewed for care plans. The facility census was 81. Findings include: 1. Medical record review for Resident #41 revealed an admission date of 03/07/18. Diagnoses included obesity, chronic obstructive pulmonary disease (COPD), and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 10/30/19, revealed the resident had intact cognition and had obvious broken natural teeth. Review of the MDS care area assessment, dated 10/30/19, revealed triggering conditions related to obvious or broken natural teeth, was a functional impairment that limited the ability of the resident to perform personal hygiene and dry mouth causing buildup of oral bacteria due to medication. The facility documented a dental care would be addressed in the plan of care due to resident was missing teeth and in poor condition. Review of the plan of care for Resident #41, dated 11/30/19, revealed it was silent for a dental plan of care. Interview with Licensed Practical Nurse (LPN) #51 on 01/03/20 at 10:41 A.M. verified the plan of care did not address Resident #41's dental status. The LPN verified the care area assessment stated the resident's dental status would be addressed in the plan of care. 2. Medical record review for Resident #64 revealed an admission date of 01/03/19 with diagnoses including emphysema (abnormal condition of the lungs normal functions), pneumonia (severe inflammation of the lungs) and chronic and acute respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 11/18/19, revealed the resident had severe cognitive impairment and was receiving oxygen during the assessment period. Review of the physician orders, dated 12/19/19, revealed an order for oxygen administration to Resident #64. Review of the plan of care for Resident #64, dated 12/31/19, revealed it was silent for oxygen (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: 365690 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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)