Inspection·September 13, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview and policy review, the facility failed to ensure bathing/showers was provided for residents who were dependent on staff for care. This affected two (#14 and #16) of three residents reviewed for bathing. The census was 48. Residents Affected - Few Findings include: 1. Review of Resident #14's medical record revealed an admission date of 07/17/23, with diagnoses including cerebrovascular attack (CVA), dementia, and multiple sclerosis. Review of care plan dated 07/17/23 revealed Resident #14 had a self-care performance deficit and required assistance with Activities of Daily Living. Interventions on 07/26/23 revealed she preferred her bathing time in the morning and a shower, and she was 1-2-person assistance for the bathing. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, and toileting. She was supervision for eating and total dependence for bathing. Review of showers for Resident #14 revealed from 07/17/23 through 09/12/23, of 18 opportunities the resident only received two showers on 09/04/23 and 09/07/23. The showers were marked non-applicable on 08/03/23 and 08/28/23. 2. Review of Resident #16's medical record revealed an admission date of 08/10/22, with diagnoses including cancer, atrial fibrillation, heart failure, peripheral vascular disease, diabetes, and dementia. Review of care plan dated 03/20/23 revealed Resident #16 had a self-care performance deficit and required assistance with Activities of Daily Living. Interventions on 07/13/23 revealed she preferred her bathing time in the morning and a bed bath. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. She was extensive assistance for bed mobility transfers, toileting and eating. She was total dependence for bathing. Review of bathing for Resident #16 revealed the resident was documented as having a shower on 07/19/23, 07/28/23, 08/22/23, 09/01/23, 09/05/23, 09/08/23. Of 16 opportunities she only received six baths during this time frame. The resident had not been out to the hospital during this time. (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: 365773 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 365773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Kettering 694 Isaac Prugh Way Kettering, OH 45429 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)