Inspection·September 19, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on medical record reviews, staff interview, and policy review, the facility failed to notify resident representative of a resident's change in condition. This affected one (#33) resident out of three reviewed for changes in condition. The facility census was 63. Findings include: Review of the medical record for Resident #33 revealed an admission date of 08/05/24 with medical diagnoses of left hemiparesis, congestive heart failure, diabetes mellitus, dementia, chronic obstructive pulmonary disease (COPD), and anemia. Review of the medical record for Resident #33 revealed an admission minimum data set (MDS) assessment, dated 08/12/24, which indicated Resident #33 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility and transfers. No skin issues were noted on the MDS. Review of the medical record for Resident #33 revealed a physician order dated 08/07/24 to cleanse sacrum wound with soap and water, apply foam dressing, and change daily. Review of the medical record for Resident #33 revealed a wound/skin evaluation dated 08/06/24 which indicated Resident #33 had one new wound. The evaluation did not contain documentation to support the location, measurements, or description of the wound. Review of the medical record for Resident #33 revealed a wound/skin evaluation dated 09/12/24 which stated Resident #33 had a Stage II pressure ulcer to her sacrum which measured 1.0 centimeter (cm) by 0.6 cm with no depth noted. Review of the medical record revealed no documentation to support Resident #33 had a wound/skin evaluation done between 08/06/24 until 09/12/24. Review of the medical record for Resident #33 revealed no documentation to support Resident #33's representative was notified of the pressure ulcer. Interview on 09/18/24 at 2:49 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #33 did not contain documentation to support the facility notified Resident #33's representative of the change of condition. Review of the facility policy titled Notification of Change, revised 02/14/24 stated the facility must inform the resident, consult with the resident's practitioner, and notify, consistent with his/her authority, the resident representative when there is a change in status. The policy stated even when a resident is mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status unless the resident does not want the notification. The policy stated a change in status would include: an accident (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 8 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 09/19/2024 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)